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SAN JOAQUI N COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> *********************************************************************************************************** <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 des of acceptance of the tank by the disposal or recycling facility The permit holder is responsible for <br /> ensuring that this form is completed and returned <br /> FACILITY NAME <br /> FACILITY ADDRESS <br /> TANK ID #39 - TANK SIZE PREVIOUS TANK CONTENTS (� L <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 City 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 City Zip <br /> Phone # (�) <br /> Date Tank Received <br /> Name Title Signature Date <br /> EH 23 046 (Revised 5/20/96) Page 10 <br />