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SAN JOAQUIN COUNTY PUBLIC HEALTH SE,fICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK WSPOSPTION TRALMNG RECORD <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 renamed 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 /> FACMXI'Y NAME: :F— -+cz_'Z, -f"Or, rn Q� <br /> FACn= ADDRESS._ L�r('�� lin on,�' ���"�-�- �`� ,�r-� C <br /> TANK M #39 - TANK SIZE:(oi 62PREVIOUS TANK CONTENTS: -� S2 A <br /> J <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> l <br /> Tank Removal Contractor. Le ��c <br /> V <br /> Address: (c e---rCiry: Zip: <br /> Phone #: ( -Iccl Date Tank Removed: <br /> SECTION 3 - To be fiiled out by contractor "decontaminating sank": <br /> Tank Decontamination Contractor: yn j I - <br /> ��„ Ciry:�\�C_c_�� � 7 rte. <br /> Address: C G--c p I - - <br /> Phone <br /> Authorized representarive of contractor certifying through signature below that the rank has been decontaminated in an approved <br /> manner as ret ui by Cal EPA. <br /> Name: —Tide: Signature: Date <br /> ------!!--!!-1Ills!ii#!##!--!!#-#i!#l!i!-!#--lil----il--l---l-##-!ili--!-----#il{iTtlO!!!!-il---#-Ittl---iii----- <br /> SECTION - To be signed and dated by an authorized representative of the awtment, storage, or disposal facility <br /> ac--piing tank and/or piping. <br /> i <br /> Facility Name: \4"4c,-'1-7� CQ S <br /> Address: 7 CC <br /> Phone #: (,!�ZCJ:i <br /> Date Tank Received: <br /> Name: <br /> Tide: Siguamre: Date <br /> F-H 23 046 (Revised 9/11/96) Page 10 <br />