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® os"NZ.FLr- V D 2w <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROL-N-D STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Scrvic^s Eavironmental Health Division Tank Tracking Sheet shall accompany each tank affixed <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 facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. S BART E <br /> FACILITY NAME:;� �„�' LO��iCTt� A/gEI�1�`�� C,�slf nt5-t2iZuTiej� Di0j2 ' cF�t�t .laA' nS, <br /> FACILITY ADDRESS: 700 E O <br /> TANK ID #39 _:*)7'q22=5 TANK SIZE: J 2,CVT> Q I PREVIOUS TANK CONTENTS: D al <br /> Dox_ t94o <br /> «#*«**##«##«=*= <br /> a=«**« +a«****««*«sae.ksj=#z«#a«###=�M#s«a#==«#«___#=##«ke««###«**s«z#«=««sr#e�««««_«_«#««=a==#=... <br /> _ <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor. C AL I NG <br /> Address: Ea 92 O O`l S9 AD Ciry: V AcAj,�,11& Zip, 257(2 S? •- �64u• <br /> Phone !#: ( , Date Tank Removed: <br /> WCTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor. tp7'c`-�-G2 <br /> Address: - - -- -- _ Ciry:-MAIM Zip: 3 <br /> Phone #: <br /> Author°.zcd 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:- Title: Signatttre: Dau <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: Z 21(x5 oi/ <br /> Address: Z S'S" PAR2 R 04,2 Ciry: R1C J%4-M e7 AJ Z2 Zip: I f&I <br /> Phone #: 10 <br /> Date Tank Received: <br /> � e• Title: Signarmt: Dau <br /> E:-1 23 046 (Revised 9/11/96) Page 10 <br />