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0 ! 5W,' FIE D D Zw <br /> SAN 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. S AAP-T E <br /> S ME <br /> FACILITY NAME:bgr-EwF_ LO&ASIteS A[jE�,—)j::EF.EmnEtST¢ty,1 mz3A SOT SAN JOAlOA;& <br /> FACILITY ADDRESS: 700 E _Py Tkj :jRom� <br /> TANK ID #39 - g 5?2 y TANK SIZE:ZD 07) 1 REVIOUS TANK CONTENTS:tj <br /> tgptp 1^uE.t_ <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor. CAL I NG <br /> Address: A 0 40 ?EA%00`! p AD City: V.4 V.-lf et Zip: 71SA la; - 6644• <br /> Phone#: ( � Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: fszs LUL-e, <br /> Address: 3,1- 4 - _ .� Cit}�,�.�.:,�-rr":,C >• -- <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 /> FacilityName: EGT / ERjCfe5oj/ <br /> Address: Z5'S P}}R2 R OAZ> City: RIC)4-M n n/D Zip: 4f8Q/ <br /> Phone#: ( 5'10 ) 2.53 •-- l3 73 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />