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SAN JOAQUIN COUNTY PUBLIC EWALTH SERVICES <br />ENVIRONAMNTAL HFALTH.DIVISION <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 />wlthin 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />chis form is completed and returned. <br />FACILITY NAME: <br />FACILITY ADDRESS: 1owe_�+'a <br />TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: We,Y�a� aa±aaxbho <br />Address:.- _2zc�L- OC City: _Gar,00n• <br />Phone #: ( ) .29-S ) Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: — <br />Address: City: <br />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 />SEC'T'ION 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: �T -- <br />Address: 2f S Pass- 3l\)d City: � M0't.2 Zip: q k 4b 1 <br />Phone #: <br />Date Tank Received: <br />Name: Title: <br />Si e: Date <br />� ##�K*******+�*pis#***sk**:kakak+k*ik*ak�►**+k******####*****#*###*******#eek**##*+b ###########et* * w#*###*�+a ######�#s u�* <br />EH 23 046 (Revised 10/19/98) Page 10 <br />