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/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERV'ICES <br /> " NYIItONL ENTAL HEALTH DIVLSIO!� G CORD <br /> UNDERGRO� STORAGE T V;K DMPOSTTION TRS <br /> srrsrwrsrrrwrswswsrrrwrwssswsrrrsrwrsrsswrwrwwwrrrrrsrrrssrrswrwrrwrsarsrssssrwrsrrrssrrrrasrrrrrrwrrrrrarw <br /> SECTION 1 - 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 this form is completed and returned. <br /> FACILITY NAME: QV 1 K SToP M A'2KFT 2 <br /> FACILITY ADDRESS: l��o W• LOUISE AVS !KA-AT& a- C�^ c? 60' <br /> TANK ID #39 - {2 L— TANK SIZE: �C)fDOO 4,,V PREVIOUS TANK CONTENTS: VNLE�60 <br /> srwrrrwswrsrrrrsrrrswsssrrsssrssrswrrssrsrrrrrsrrrssrrsrrrssrwwsrwsrwrrrrrsssawrwrsrwssswsrwwrwrwrrrwsrrwrs <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: WA LTe/^1 <br /> El�)bin����� lnlC• <br /> � t o2S <br /> City: W. SAC4- WTC:> Zip: <br /> Address: > R gSb`l 1 <br /> Phone /t: ( Cr 1 (al ) Date Tank Removed: <br /> wwsrrrrwwrwwwwwwswawwrrws.nsrarr:rrrrrr+rr+tsrwrsrrwasrrrrrraer*rrwr+�wwrwwrrrsars:rwrrrr.rwrasws+rrrsrrarrrsar:w <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> �a ��X t,•a2S City-\p. $AC.7o. Zip: <br /> Address: <br /> Phone : 3-73- i 16S <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 /> Title: Signature: <br /> Date <br /> Name: <br /> wrwrrrrrrwrrwrrwrrrrrrr:ti.rrrs+rsrrrrrrrsrrrrrrrrrsrrarrr,�s*+�wrr*rrrrwrrrs+�r:r=sr.srrrssdr���facility <br /> SECTION 4 - To be signed and dazed by an authorized representative of the treatment, storage, or <br /> accepting tank and/or piping. <br /> Facility Name: az I C /N C. . . <br /> Address: 253' <br /> Ciry:oG/'(/hO� Zip: <br /> Phone #: 5C13 <br /> Date Tank Received- <br /> _ Dace <br /> Name: ' <br /> Title• Signature: <br /> rswrrswsrrwrssrssrsssrrsrrsssrrssrrsrsrrrsrrwrssrwrwrrrsr+►wrs+rrrwwwwsrswssssrss+rr+srsssssr:sssrrsrsrsrrrs <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />