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S JOAQUIN COUNTY PUBLIC HEAL VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> :aa###aa«###as#s#######ss#a#assssss#sae#ss#asasa##s#aaass####s#asssk####aa##as#as#ss#«a##s#aa####sa##s#s«ar <br /> SECTION I - Public Health Services Environmental Health Division Tank TrackinCP <br /> g 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 recycling facliry. The permit holder is responsible for <br /> ensuring that this form is completed and returned. sM�F- <br /> FACILITY NAME:I�KEoI 'rl OG�!<'C►� rA-;EI�I�Y e�urt T7�STQt tT1f 4.1 L:8= 156M JO/ f-,U; 3 <br /> FACILITY ADDRESS: 7U0 ff. P,-7TA -2081 <br /> TANK ID #39 - A►5rG RZZ TANK SIZE:Z-0 0 j_PREYIOUS TANK COMMENTS: wsL�,4t>za F- <br /> Z)or.. 10 <br /> .«#«a«aa###** <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor: C. AL 1 NC. <br /> Address: �. O'-f O Y EA Z O D Y SO AD City: V 4cA Vr Ll.ff Zip: ` 52 - (-04 <br /> Phone #: (_ ) Date Tank Removed: <br /> ««aaaa«#««aa«««#««a««###«««#a« <br /> SECTION 3 - To he find out by conzz-actor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> J <br /> Address- 'A n &2R <br /> Phone #: ( lLz) •' �- <br /> Authorized representative of contractor ctrafying through signature below that the tank has been deconrami=ed in an approved <br /> manner as rewired by Cal EPA. <br /> Name: Title: Signature: Date <br /> SECTION 4 - To be signed and dazed by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: EGS Rl�x sem✓ <br /> Address: 2 S-.S'" PAR2 R 014D City- RLrh!tj n,yZ2 Zip: ILROZ <br /> Phone #: ( 15,10 ) <br /> Date Tank R=ived: <br /> Name: Title: Signaturc: Date <br /> • aaa#«#etas##a#ass«##«#«�aasaas##a+kuaaas#a1ca#s+B«##sok#s«a;nuAt#«##s#as*s«««###asa+ecaaa««#«se««««eases#««ac#s«aa«a <br /> EH 23 046 (Revised 9111/96) Page 10 <br />