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SAN JOAQUIN COUNTY <br />PUBLIG rW wISAVICES <br />UNDERGROUND STORAGE TANK DISPOSMON TRACKINGRECORD <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank of%Yed with <br />its site identification number.. To Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />withig 3 of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />chis fort: is completed and returned. <br />FACILITY NAME: �' _)rNQ ron <br />FACILITY ADDRESS: l-Qw e!- SaC-t'a M e n goo f� — <br />, <br />TANK ID #39 - TANK SIZE: IMC0 6) PREVIOUS TANK CONTENTS: <br />««+c#*K#*#**##***##**+k*ir*****#k#*kaM###***#*##**###**####****#***#**##*#«***««####+Ikv � rk#«Y#«m«�•*«####+Kms ***v <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor:_ Wend- assicL Albo — <br />Phone #: Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: <br />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 />SECTION 4 - To be signed and by. an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: ` <br />Address: S poxr PA\A City: nM9n Zip: q_ 46 <br />Phone #: ( ) 235- 2 93 — <br />Date Tank Received: <br />Name: Title: Si e• Date <br />EH 23 046 (Revised 10/19/98) Page 10 <br />