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i. SAN -AQUIN COUNTY PUBLIC HEALTH SER*-ES <br /> ENVIRONMENTAL HEALTH DMSION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> at <br /> rrrrtlfrtfrtrir#aft#irfrrlfirtrrli#riff#iriffi#r#r#awliirirrtw!#ri##are!!#af##rir!#ilaf!#f#r#fella!#rfirtrrlwff#f <br /> SECTION 1 Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. / <br /> FACILITY NAME: lgcore 7-tz�M line 5 <br /> FACILITY ADDRESS: ,34490 /V?Q)A / /4l s&alt:rn C� <br /> TANK ID #39 - �TANK SIZE: (-_PREVIOUS TANK CONTENTS: CL/ � ` <br /> frtfirrrrtflaaf#rrtrtrr#rlia##.ar.#arta#irtrrlaarif.rtffrfwrtfrwfrawrw!#1rfwilar#it#.ifrri#rf#.aarrra#rriii.iaartw! <br /> SECTION 2 - To be filled out by tank removal contractor: A <br /> Tank Removal Contractor: <br /> Address: Ci <br /> .21p9 D��a� ry: Zip: <br /> iC/�e� Q� o <br /> Phone 5y9--23,17 Date Tank Removed: <br /> #frtrrrtrrtrlfirrtairi!liwrf#�ear�!arrlearlrrarrarrrrrirrliiirrirrrlfrrrrrlrfrrir#rrrrr#rr#r#...rile rrr#rrririi <br /> SECTION 3 - To be filled out by contractor "decontaminating tank":,l <br /> Tank Decontamination Contractor: <br /> Address: J4� City: AIV021 Zip: <br /> Phone M: ( Qq <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: C 147C Signature: t6-Date J 1 I <br /> lrtrarrrrfriffr#iifrrrirfrrrrafrrirrrifrrtafrfriirrrfrirfrwiirffrrafrtr#wfrrrrrrwrrarla#affairrirtaffrirtfarlfrrt <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: 6/- <br /> Address' /-I�/o �C1t't/t�d City: Zip: <br /> Phone #: <br /> Date Tank eived: - <br /> Name: Akle: Signature: Dace <br /> leer **rrrrr*rrrrrfrrrrrrrrrrrrtrrrrr■rrrrrrrrrwrtlMr�rrirrrrr**r�rtMoil*11rrtlr�rr#*rrrtrlrrrtrr��►rtrlrw�rrrrl�lr <br /> EH'Z3 046 (Revised 10/19/98) Page 10 <br />