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i 0 5uUR-PLE D D IZ W <br /> SAWN JOAQUIN COUNTY 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 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. 514AP-T <br /> S r -� <br /> FACILITY NAME: rear L06aGTuGS ENc-Y. UIEWE nIST9IZWC1fAA tgT E SAN JDAQU; <br /> FACILITY ADDRESS: 700 E. -ArTfu CoA N <br /> TANK ID #39 a1Z4$2 3 TANK SIZE: 007) PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: C AL I NG <br /> Address: 'X 0 4 0 P FA e O O Y R o AD City: VA vill's Zip: `IS6%; - G(,4gt <br /> Phone#: (_) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: ptz- � <br /> Address' �.n 2Ar�a n, -�-- �� -irr nen i�r iKic Zip. <br /> Phone#: <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 /> *********************************************************************************************************** <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's E RjC-X 5 0✓ <br /> Address: 2-S7-S' Ph,&R ROAD City: Rre;j-rtnwla Zip: 94,&1 <br /> Phone#: ( in ) 2-S3 — /3 7-3 <br /> Date Tank Received' <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />