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SANqOIAQUIN COUNTY PUBLIC HEALTH S ICES <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 with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: <br />FACILITY ADDRE <br />TANK ID #39 - <br />TANK SIZE: PREVIOUS TANK CONTENTS: OJRS- OIL <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: <br />Phone #: ( ) Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: <br />Phone #: ( s/) ) Ol "/, 3 <br />City: <br />Zip: <br />1�6-)114jzip: W <br />�A:z <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 <br />Title: <br />Signature: <br />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. f <br />Facility Name: F,- —O & <br />City: A Zip:�; U/ <br />Address: <br />Phone #: ( 5/0) <br />Date Tank Received: <br />Name: <br />Title: <br />Signature: <br />EH 23 046 (Revised 08/13/99) Page 10 <br />Date <br />