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su � DpRw <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ® UNDERGROLUrD STORAGE TANK DISPOSITION TRACICI G RECORD <br /> :...ffiffi#ffiz z=z#zzffizffi.ffiffiffiffi.#ffiAke»t##########z#Kz##z#zk####kzz=##Ie####ffi#z=e=###ffi=FIs#kaa=:K#z#z##A=zzz#le Kaa <br /> T 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank afill ed <br /> e identification number. Tae Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> -ithin 30 days of ac;eptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> :at this forst is completed and returned. Sl�/FTZYE <br /> 5 tT� <br /> NA:�fE:�EF�T1rF LOC-e1S'"CirS44 5,w- (� C Ift- T�tSTt2t2LrT�f1,1 I`s��Sr SAN JOPs %t�� <br /> . ADDRESS: 7U0 E. ?r:ru 120AN <br /> TAPIK SIZE:.LZ_C 9 a! pREVIOUS TANK CONTENTS:_D <br /> Z - To be filled out by tank removal contractor. <br /> val Contractor. CAL 11yG <br /> O Lt0 ?EA BOUy S D City:_ VgcAt,.,IIE Zip: (.04 <br /> S? - (.04 <br /> Date Tank Removed: <br /> 3 - To be filled out by contractor "decontaminating tank": <br /> 'tunation Contracmr: <br /> z.., 2zpQ 1- G_Cen TrJ�� <br /> —- - 7- City-- <br /> e-=resentadve of contactor c:rdfying through signature below that the tank has been de.^.onraminar an approved <br /> quired by Cal EPA. <br /> Title: SignaM=- Date <br /> - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> EGT / EF21Cxsa <br /> SS' P�4R2 R Q4 n City-2hc 9Zn„v im Zip: 2.1t <br /> �!O LS"3 -- X393 <br /> ived: <br /> Title: Signature- Date <br /> ;Revised 9/11/96 Page 10 <br />