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• • 5"4Z-?L= D D p.w <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL. HEALTH DIVISION <br /> ® UNDERGROUND STORAGE TANK DISPOSITION TRACT 3NG RECORD <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Shit shall accompany each tank aMted <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 rerfcling facility. The permit holder is responsible for <br /> ensuring that this form is completed and rerumd. 5 AARP E— <br /> S rrE <br /> FACILITY NAME: EFS;;L� I.OGt /9 Eh1� C�r.tt►= T�rST12tR t c-71, 1 NTOT 5611 .10AOUI <br /> FACILITY ADDRESS: 700 E STA 20At.) <br /> TANK ID #39 IRG 2 1 - TANK SEE: 20001) PREVIOUS TANK COME-NTS: DISS L- <br /> "Do= 1`1:F0 <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor. CAL l NG - <br /> Address: D. 0 4 P;-7-A600Y 92 AQ City: V aCAV,llg Zip: a(2 8:j - 6(.24 <br /> Phone #: (_? Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor- 41t--d�L�, AS 4.'Ont.� h <br /> Address: 3Q <br /> Phone : <br /> Authorized repres=tative of contractor certifying through signature below that the tank has been decontarni afd 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 /> ateepting tank and/or piping. <br /> Facility Name: GZ -guag s®e/ <br /> Address: ZS"S" PkR2 R 0,4D City: IG).Mt 42 d Z2 Zip= 4-&Z <br /> Phone #: ( SlO ) LS3 -- 13 23 <br /> Date Tank Re=ived• <br /> Name: Title: Signature: Dau <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />