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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION T - 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: Ie?Bolo des Retrnt eurn <br /> FACILITY ADDRESS: 2191 Navy Dr . Stockton, Calif <br /> TANK IID 1139 - TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SEC'T'ION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Sa e! G e ngt r-u ei r,._ <br /> Address: P . O. Box 737 CirM gip:T 99292 <br /> Phone #: (209— ) 931-5513 Date Tank [removed: <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: Title: 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 /> +kkk+l�#+K***�kqe tle 9e,k Ae lei 1klY**�[********#**#F*******�k if yc yc�R**h***yey[�*�N•!c ele M,lc*lYffLytf[*�k*w��k**�k ok�F�k*�RIIc,Rlt,R![eR1ky��K 1kY**7n1[li[**]keltyelklk ilc]Ic <br /> EH 23 046 (Revised 911.1/96) Page 10 <br />