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9 • SUh(Z P¢ D D Rut <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> *********************************************************************************************************** <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 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. SAAP-T6- <br /> S Cts' <br /> FACILITY NAME: F►.►tF_ L06JSTILS A,�9E.^e-Y,T t tZt,4Tt42hj 1 llf SRN JOAQ <br /> FACILITY ADDRESS: 700 F. P47A �2oPrD <br /> TANK ID #39 kl .$� 1 TANK SIZE: 20 Ml> PREVIOUS TANK CONTENTS: VIE-SF,l._. F-,A i L.:6-Z. <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor: C AL I IVC <br /> Address: A 0 40 'PEA%O DY Ro AD City: V-4 vill s Zip: 456 87 - 6644 <br /> Phone#: ( ) Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Pio AS F64zi_V.0Aak,s � <br /> Address: S� _ &�Q <br /> Phone#: (s <br /> Authorized 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: 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: EGS E 2,CJe 5 0✓ <br /> Address: ZS'S P I" R OAD City: Ir-14-M n A/D Zip: 9480/ <br /> Phone#: ( .5'10 ) 2-S3 -- /3 93 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />