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SAN JOAQUIN COUNTY PUBLI <br /> /WVYVIRONN, MYPAL HEALTH DIVMON-- <br /> UNDERGROU�STORAGE TAINK DISPOSITION T;aO%4G RECORD <br /> rrrrwrrrrrrsrsrrrrrrrrrr.rrrrarss*rrrrrrrrrrssrrarsrs*rs*s.rssr*rrrrrrs�� shall <br /> ��sr� «�� �� ���ssr <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking mP Y <br /> with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Servichal 1�vironmeaHealth <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The perm responsible <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: 6ZV1K SToP / �KZT X121 <br /> FACILITY ADDRESS: <br /> W. �owise tl6 Mazza 9'533 <br /> TANK ID 1139 - 12I— TANKS :_ )g.^ •PREVIOUS TANK CONTENTS: V"fy�eD C�tS <br /> #rr#r##rrrr*f.rrFrsa##rr#rrrrrrrrrrrsrrrrrrrrr*rrrrrrr*rrrrsrrrarrrrrr*#rrrrrrrr#r#rrrrrr.s <br /> rrrrr*rrrrrrrsrrr <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor. <br /> WA LT,A) ElQ 61 r3 61E- L - /NC• <br /> Address: 'Po l�X <br /> I o2S City: w- SgGl.'h�'t�o Zip: 2�`I 1 <br /> Phone !#: ( Cr 1 (0 Dace Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> NC <br /> Tank Decontamination Contractor. WAl-'Zon1C�I r-► �1 <br /> �D Q7oX La2,5- Ciry:W <br /> $1�L7o- Zip: q�q <br /> Address: <br /> Phone #: ( � 1�� 313- 11G& approved <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an a <br /> manner as required by Cal EPA. <br /> Title: Signature. <br /> Date <br /> Name: <br /> rrssrs**s**sss**rassrs*rsr**ssss*s*r*rrs*srrrs**+R************srs*r*�******ssssss*sss*******s*ss:r*rs*sssa.+. <br /> d representative of the treatment. storage, or disposal facility <br /> SECTION 4 -To be signed and dated by as authorize . <br /> accepting tank and/or piping. <br /> Facility Name: 1 C K-SD'� INC. <br /> Address: P. <br /> city:�1CeA <br /> e, Zip: <br /> Phone #: <br /> Date Tank Received: <br /> Tide: Signature: <br /> Date <br /> Name: <br /> #rrrr*rrrsrrrrs**+w.r.rrsrr.ss*r*rr.rrr.#s#s+#nrrrrs#rr*sr*.*r*.r.+rrirr**lssrrws.rrs*sr+Rsrarr.rrss*r <br /> EH 23 046 (Revised 7110/96) <br /> Page 10 <br />