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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACX3NG RECORD <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each rank affixed <br /> with its site identification number. The Tank Tracking Sheet is w 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: A C.,1, iW N WN,, - r 07-4 <br /> FACIL= ADDRESS: ��� w ���o u -- cr ` .r• C <br /> TANK M #39 - TANK SIZE: lOrc��G=e kYPREVIOUS TANK CONTENTS: QQ S61i h Q <br /> v <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor- <br /> Address: <br /> ontractorAddress• l01 F (<'; L�T�4`'#- City:~ I Zip: <br /> Phone #: r S Date Tank Removed: <br /> -----------YYM#----#:-MM-----#YM:--/-a!##-M:sa--::-----Y-a#YM-M--#-M--Y]�--i-a-aMa-Y:Mai#--Y-ill-#-:##-fIUYYYYMY <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tanis DerIInraminarioII Contractor: l 1' r '��"" t �� v�C Y1 M•% �—�S C't=Nl C C t 7 n/ •-- <br /> v <br /> Address: L G ~ \A L_ CiryZip: •��� rte. <br /> Phone : (4�' Ci -t� C,7 <br /> Authorized representative of courrac:or certifying through signature below that the tank has been derontaminared in an approved <br /> manner as required by C-d EPA. <br /> Name: Title: Signature: Daze <br /> a---YM---M#i-Y------Y----Y--a---M-i#--MM#Y-M---Y--M#-M----------#--YM---YY-YY#------ <br /> SECTION 4 -To be signed and dated by an authorized representative of the amanent, storage, or disposal facility <br /> accepting tank and/or piping. <br /> l <br /> Faelity Name: kA-is<� C—n1r <br /> Address: r�CIC-, ti. a� .�,e; f 1—v� City:`T ��\e.0 t� ZiP: <br /> Phone #: <br /> — l <br /> Dare Tank Received: <br /> Name: Title: Signanure: Date <br /> lll-#a--a-----Mama,s-a-#M-iraa-Y-YMM a--Ma M-MMM---#-----#--#gtflf#-fY{Y-iRY#-flf-flf----Y-lllfRfkiFfR#flf Y---#YY�-ff1f11-#Y#-#-#-YYY <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />