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® SU0.,2PI� D p2.w <br /> SAN JOAQUIN COUNIY PUBLIC HEALTH SERVICES <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 <br /> with its site identification number. The Tank Tracking Shest 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. Tne permit holder is responsible for <br /> ensuring that this form is completed and returned. 55M�l; <br /> FACILITY NAME:]E to aIcF LD-.IC-T1C,5 nt4-T2tZ;A't't i t` OT SRN .10AiQtri 4 <br /> F ACILITY ADDRESS: 700 F ter:t;t �oP t� - <br /> �+c <br /> TANK ID #39 -41ge 9,Z-6—TANK SIZE: 17-022 I'll <br /> PREVIOUS TANK CONTENT tL n r� <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor. CAL.. I NG <br /> :Address: O Lt0 p 6o4Y RQ ADCity: VgeAc�,11 'P: 75151 <br /> Phone #: ( � Date Tank Removed: <br /> SECTION 3 . To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contract <br /> ntaor. p4peerle ���—Trite /�S '/� >�r��or�•�5 <br /> Address: <br /> s, City: a <br /> - - <br /> Phone „f: <br /> J <br /> Authorized representative of contractor certifying through signature below that the tank has be--a decontaminated 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 /> accepting tank and/or piping. <br /> Facility Name:_ ;=Q Cx s o✓ <br /> Address: A!2,4 D City: RXbh=n,/D ZIP: 2:E&Z <br /> Phone #: ( $'10� Z.S•3 13 93 <br /> Date Tank Re=;.Ved- <br /> Name• Title- Signature: Date <br /> EH 23 046 (Revised 9111196) Page 10 <br />