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SAN JOAQUIN COUNTYHEALTH SERVICES <br />ENVIRONM[ENTALHEALTH, DIVISION <br />,Vi?,r 1 iy i .. "it_, D <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 dans 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 />r <br />L64uroo <br />FACILITY ii. ► , 11 A clot 1\ r <br />TANK ID #39 - <br />TANK SIZE: JW0 &gj PREVIOUS TANK CONTENTS: W0-SkTOe I <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: WL'n Asiru cubo <br />Address: 0 City: n Zip: cl.� <br />Phone #: (-20-q-) -5Ll9 -11) () Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor:% <br />Address: <br />Phone #: (�) <br />City: Zip: <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: <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. <br />Facility Name: ECZ Address: 2S pAc�CC �Aoa City: n \C�h rn.Qgn A Zip: C 6 ) <br />Phone #: <br />Date Tank Received: <br />Name: Title: Signature: Date <br />EH 23 046 (Revised 10/19/98) Page 10 <br />