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.i•m a ..� r !/ •�. w <br /> SAJOAQUIN COUNTY PUBLIC HEALTHVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> U°iDERGROUND_STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sh=t 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 facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. S HA P-T EEE <br /> 5n7E <br /> FACILITY NAME:j�E^,arF LO&1,5TtC,5 A(9E,�,_�C���} T')iS1'I21Yl,tTinA L2021 SAN JOPcr�'iUt <br /> FACILITY ADDRESS: 700 E 2-=A :206n <br /> TANK ID #39 -T%h i x4 R2 3 TANK SIZE: CV0,IPREVIOUS TANK CONTENTS: t-�D7 - ��_ <br /> Do; t�Yo <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor. C, teL INC. <br /> Address: L O L+O PEAeOOY 90 AD City VAc4le lIg Zip: <br /> Phone R: (_ ) Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": gq � <br /> Tank Decontamination Contractor. eao= a <br /> Address: ,3 r n l�T.eO a >� �, r <br /> Phone #: -9-10 <br /> Authorized representative of contractor terrifying through signature below that the tank has been de-contaminamd in an approved <br /> manner as rewired 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 /> ac:.,-pting tank and/or piping. <br /> Facility Name: --Z-/ <br /> E 1CJG 5 oe/ — <br /> Address: ZS-S P999 R C2,4 D City- R is ki-m a d Z2 Zip: 4►BOZ <br /> Phone #: ( .5,lO ) LS3 — 1-37-3 - <br /> Date Tank Rec.-ived: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9111196) Page 10 <br />