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0 <br />• <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*********************************************************************************************************** <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. <br />FACILITY NAME: <br />FACILITY ADDRESS:�'���'���T� <br />TANK ID #39 - <br />TANK SIZE: /�VO PREVIOUS TANK CONTENTS:��'% <br />*********************************************************************************************************** <br />SECTION 2 - To be filled out by tank removal contractor: qq <br />Tank Removal Contractor:�� !✓J C' <br />Address bl�l „fl Tc �� City: �,�� Zip: <br />Phone #: ( � ) S5-) ' 7 Date Tank Removed: <br />*********************************************************************************************************** <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Eel / <br />Address:City: /`�i✓�'Ca� f 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 <br />Title: <br />Signature: <br />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 />Facility Name: i <br />Address: .- aJ % ✓ ✓ ? )6Lv p City: \ jZj1;a% "),jr Zip: <br />Phone #: (-')� V) a � <br />Date Tank Received: <br />Name: <br />Title: <br />Signature: <br />Date <br />********************************************************************************************************* <br />EH 23 046 (Revised 9/11/96) Page 10 <br />