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w <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACING RECORD <br /> #.rrr.rrr.rrrrtr.r+�rr......................rrrrrrrrrr#rrrrrrrr#rrrrrrrrrrrrrrtrrrrrtrt.......... wrrrr...rrrrr <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 ensurmg that <br /> this form is completed and returned. T / <br /> FACILITY NAME: /-Icor /IZ�LI K �ll�P S <br /> FACILITY ADDRESS: 34c/20 <br /> OO <br /> TANK ID #39 - � �� — C 7 TANK SIZE. L _PREVIOUS TANK CONTENTS: Le <br /> rrrr.rrrrrrr.rrr#rrrrr#.....tart.r.r.r#r.rrrrrr#.tart.rrrrr#r#rr.r.rrrtrr.rrr...rrrrr..rrrr..r..rrrrr.r.rr.r <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: P�((.Y►Y�' �,�'Cat/Qfi� l <br /> Address: J&9 jwm City: Zip: �� o <br /> Phone /1: ( � l ) 5y4 Date Tank Removed: <br /> ra#r.rr.rarrrrr..rrrrr...r..r.#*..#rrr#rrr#.rrrrr.rrrrr..ratrr#.r..rrr...r.rr....rr..rrrrrr..arr.rrrr.ra..r <br /> SECTION 3 - To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: �Vd/r>L <br /> Address: l(o City: f17/�lm Zip: <br /> Phone 4: (� `f <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•. !� t Title: C 7'- C Signature., Date <br /> ie <br /> rrrrrrrrrr.rrrrr......r....r.r..r.r................................rrr..rr................................. <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: �G�' LY �If29 <br /> Address_. f��o /�aJamd City: Zip: <br /> Phone : <br /> Dace T ceived — c <br /> Name:� ` + Title: Signature: C <br /> __ a ;• .> <br /> r###.rrr##rrrrrrr.arrrr#rr##rrr#rrrrrrrrrrrrrrrrrrrrrrrr###rrrrrGr#rrr#rrr#•####rrrrsrrrr#### rrr#r##rrrrr <br /> EH 23 046 (Revised 10/19/98) Page 10 ! . <br />