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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. 5 AATRT E <br /> S rrE <br /> FACILITY NAME:�EFE-MCF L -,AGTlCS &fgEN_��5:Ehl(9- niSmZtATt/'7►.1 U021 SAN ADARIt�n(� <br /> FACILITY ADDRESS: 704 E A TTNi2OAN <br /> TANK ID #39 - q $2 6 TANK SIZE: 12 PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: CAL LNC <br /> Address: A 040 PFAZODY fro Aja City: VA Zip: `1St.S; - (.04 <br /> Phone#: (_� Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Pee0" <br /> Address: _ City: &1 �.7 - �: a�.e-�5 <br /> —�� .�� <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 /> 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: EGT Z E(ZIC-<50✓ <br /> Address: ZS-S PAR2 ROAD City: RIG)4-rt Q n/i7 Zip: 74-ft <br /> Phone#: ( S!D ) 2_5'3 -- 13 73 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />