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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> • ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identification number The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility The permit holder is responsible for <br /> ensuring that tlus form is completed and returned <br /> FACILITY NAME <br /> FACILITY ADDRESS <br /> TANK ID #39 - /17,,S-07— TANK SIZE J 0 k_ PREVIOUS TANK CONTENTS (A � <br /> SECTION 2 - To be filled out by tank removal contractor <br /> Tank Removal Contractor <br /> Address City Zip <br /> Phone # (__ } Date Tank Removed <br /> SECTION 3 - To be filled out by contractor "decontaminating tank" <br /> Tank Decontamination Contractor <br /> Address Cita, Zip <br /> Phone # ( ) <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA <br /> Name Title Signature Date <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping <br /> Facility Name <br /> Address <br /> City Zip <br /> Phone # ( � <br /> Date Tank Received <br />.Name Title Signature Date <br /> ********************************************************************************************************* <br /> EH 23 046 (Revised 5/20/96) Page 10 <br />