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D D P W <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> :-r=ON 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affhted <br /> ;Eh its site identification number. The Tank Tracking Shut is to be returned to Public Health Services Environmental Health <br /> ivisien within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> curing that this form is completed and returned. SIi�R�E <br /> S� <br /> i,CILITY NAME: !`)EFotr� !_06.1,GTtCS -A talc , cP,��� 1�i 't2t�u'ris�1 rT SAN JDA U;c <br /> ;CILITY ADDRESS: 7W E "?=a 2oAN <br /> ;.,NK 1D #39 - 9 F2 y TANK SIZE: SSO en PREVIOUS TANK CONTENTS: <br /> :CTION 2 - To be filled out by tank removal contractor: <br /> rk Rcmoval Contractor: C AL l NG <br /> .dress: O t-{O PEA B o Dy go Ar City: V q te)11 Zip: 4S6 52 - (.24 <br /> one : �_) Date Tank Removed: <br /> CTION 3 - To be filled out by contractor "decontaminating tank": <br /> Decontamination Conta-actor: O f7-�91.t,c-, 1-1A 6' ±1,4 , <br /> i <br /> dress City: ZIP: <br /> :hor.=d representative of contractor c.-rdPling through signature below that the tank has been decontaminated in an approved <br /> finer as required by Cal EPA. <br /> ne: Title: Signature: Date <br /> -TION 4 - To be signed and dated by an authorized representative of the t=eem, storage, or disposal facility <br /> accepting tank and/or piping. <br /> diry Name: EGS ER1CK50As <br /> Tress: 2-= PA22 R 0,4 D City: Rfcg-M a A/2 Zip: <br /> ne R: !O <br /> Tank Received: <br /> Title: Signature: Date <br /> 23 046 (Revised 9/11/96) Page 10 <br />