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SAN JOAQUlN COUNTY PUBLIC HEALTH SERVICES D+ UNDERGROUNSTORAGE TH rAL HEALDIVISION TANK DISPOSITION TRACKING RECORD • +ww*w*rtwwwwwwrtw*ww*ww*w**w**w*w�,+*w+*w*w*+rtwww**w+*,w+**+*s+*w****wwrt+++**+ww+**r****w**w*wry+*www**w,�*w SECTION I _ public Health Services Environmental Health Division Tank TrackingSheet � its site identification number. **w** within 30 daeach tank affixed with P The Ttank ank Tracking Sheet is to be returned to Public Health'shah a acEnvcompany m nth Health Division this fog completed and return de by �e disposal or recycling facility. The permit holder is responsible for ensuring that FACILITY NAME: 6– FACILITY ADDRESS; iv TANK ID#39 -G� ._�wK TANK SIZE: /Z — 2 PREVIOUS TANK CONTENTS: �iE.S,EL �+***w+wrt*w+wwwwwww+wrt+w***wwrtwwwww*wrtwwwww+wwww***www***w*****ww**rt+wwwwrt***ww**,�************ SECTION 2 - To be filled out by tank removal contractor: ***wwwwwwwww+ww ,.,,Tank Removal Contractor: Address: Z?,7 Typg sT 'Phone#: (�,��) y City:T!'2CGC.t� Zip: � Date Tank Removed; +ww*w*wwwwww**rt*wwwwww+wwwww+w*w**ww*w*w**wrt+w*wwww+**ww+w*** wwww*ww**w+*****+**+*w "ECTION 3 - To be filled out by contractor "decontaminating tank":ww**rt+ ank Decontamination Contractor: I. Address: lone#: ( � City" Zip: i Authorized representative of contractor certifying through signature below that the j" Mner as required by Cal EPA. tank has been decontaminated #,. tamirtated in an approved Name: Title: + *wrt*w+w+wrtww**rtwrt*wwwww*«wwwrtww**,w****www*wwwwrt***wwwww*wgna*ture*+ Dale TION 4- To be signed and dated by all authorized *www**ww*******ww*ww*w****w*w*****w*www acce tin representative P Stank and/or piping. Of the treatment, storage, or disposal facility 'i--litY Name: tone#: ( City. Zip; t Tank Received: 60 me: • Title• Signature: Date �.,rt**+'"********ww+wrtwwww*w**rty,rt*w+wrtww*wrtww+ww+wrtwwwwrt+wwwrt*w+wwwwwww*+w*wrt*w**w*w*rtww*rtrt+w**,K* 046 (Revised I0/19/98) **+wrt*rt � Page 1p a.