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0 0 SNA?.Fr- D D R,%J <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUNTI) 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. 51iA1ZTE <br /> S rrE <br /> FACILITY NAME:b urnsirF L06dSTtc S ���ENS Y ):�E5Ljf e t S-M i Zy-D f2hi I :� SA m J Q6Qu <br /> FACILITY ADDRESS: 766 E. A--rT A :j?oAN <br /> TANK ID //39 -�G 5?2ANK SIZE:I z,UI PREVIOUS TANK CONTENTS:tj <br /> _ptEs�` <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: CAL L NC <br /> Address: A O L}O PEA 6 O D Y 2 0 Ate City: VA villis Zip: `1SG S' - 404 <br /> Phone#: (_) Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: PoNcy <br /> Address: C T City-- <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 /> FacilityName: EGr Z E2lCX50✓ <br /> Address: 25-5 R49jR A04D City: RIGA-Mnn/a Zip: 74-ft <br /> Phone#: ( .15 /0 ) Z5"3 — /3 73 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />