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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EjwmONMENNTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 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: <br /> — mi-1 'R-kides -Retrnleum <br /> FACILITY ADDRESS: 2191 Navy Dr . Stockton Calif <br /> TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: P. O . Box 737 Ciry:ya l l ey 513r_jaq gip: 99252 <br /> Phone #: (209- ) 931-5513 Date Tank Removed: <br /> ilk==Ir###i****rlr�r Krk#=#####=##F Iryr#=�yrfrMr#olrRM*##fir###+Irl�!•**7rrlerirYM#yr#lM#*####.Ir**rk kl+k�lryr rlr lrlY tk W1�.Ir iirlR lklk Ir#yr rp.M*s#=#Ir##rM#Ir# <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Same as 2 <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: Tide: 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 /> =r�=rrr�#=:rr*:rkar�*k**r*r�www.*>,r�#�r,k:�rx W*�rw■��r*****�r**r��x***.*��*�*ars*�rsr�**rrr**=*:*::##ar**«*rr:�**�r�*�>«**>k*# <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />