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qS"NZ-Fr- DDQ-W <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 HAP-T E <br /> S rrIE <br /> FACILITY NAME:bore aCF- LD&IGTtrS �(gE1�1_�_Yt���1["� txTi4jj [ EMIT SAN JOAQi n <br /> FACILITY ADDRESS: 700 E —PrTf N �2oAN <br /> TANK ID #39 µsq R'ZS TANK SIZE:12,WI) PREVIOUS TANK CONTENTS: D <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: - AL l NC— <br /> Address: <br /> GAddress: O 40 4rA%0 OY (2o AD City: V-4c-AV ll& Zip: `1SG 8'; - 6644 <br /> Phone#: ( , Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Fwsim �L}LSI h LLA-7 i9K C <br /> Address: 91tR City: 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: EGA EIZIC-<5011 <br /> Address: Z.5'S' Pi4R2 A 0AD City: Rrc�M Q Al Q Zip: 14-ft _ <br /> Phone #: ( vr_!D ) ZS"3 -- !3 9-3 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />