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� k <br />0 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SER CES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 />,pC�FGMS'6 �7fS`ToE'/l3t�T-r® ,C7E/oeT" <br />FACILITY NAME: s)F. rE S C- �`Q,4 & Q®/Y S' WR P 6 r T� <br />FACILITY ADDRESS: 7Q Q C- X0 7W ? <br />TANK ID #39 - TANK SIZE: 1j-4&06,4W—PREVIOUS TANK CONTENTS: L�1SE� <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: ECF®/Y .G (L <br />Address: Z �— 6)1 T"/g" Ca 7-/ -9 i"E ® p City: j2C'9,qYn cW 7'6 Zip: <br />Phone #: ( /,/ ) g� -? J Z6 % Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: <br />Phone #: ( ) <br />City: <br />Zip: <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 <br />Title: <br />Signature: <br />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: <br />Phone #: ( )_ <br />Date Tank Received: <br />Name: <br />Title: <br />City: <br />Signature: <br />0 EH 23 046 (Revised 08/13/99) Page 10 <br />Zip: <br />Date <br />