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! , s"W?-PV DDR.w <br /> SAIII 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. SAAP-E <br /> S rrE <br /> FACILITY NAME:�t:FejyF LD&AGT1GS pt/gEN Y. tE5je.mn; IST¢tZtxTt4jj 1�2lJf SAN JOAQint; <br /> FACILITY ADDRESS: 7WE. !��'TTN BORN <br /> TANK ID 1139 - TANK SIZE:_SS"O PREVIOUS TANK CONTENTS: c,�,,/t,raotc o FuFL <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: CAL I NG <br /> Address: ;X 0 40 ?V--'A60OY Ro AD City: V-4 Lodi& Zip:_75*9 S-ti - 6644 <br /> Phone lt: (_) Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: � / <br /> O /`7�i9llt <br /> Address: City: _ Zip: <br /> Phone 11: <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: Er.-T-1 t=Ric-W-50W <br /> It <br /> Address: Z.S-S PhM A0AD City: RfG)4-mn,-j,-,7 Zip: 94-ft <br /> Phone Il: ( 10 ) 2-S3 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />