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SAN JOAQUIN COUNTYHEALTH <br />ENVIRONM:ENTAL HEALTHt <br />UNDERGROUND•`AGE TANK DISPOSITION TRACK[NG•'D <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: I-A',I tS MA t' 49-K. t✓ T <br />FACILITY ADDRESS: �3o0 WeST LANA 5ZociG.7co1 CA �/$ZbG> <br />TANK ID #39 - 00 - tW TANK SIZE:_0,000 PREVIOUS TANK CONTENTS: Vnll.&-X*Df 6,t5 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: R (C V- WA UToA) <br />Address: iso BoX CO25-A e-3 R.tS�--e C.N City: W, Zip: 9S6 71 <br />Phone #: (q i 61, ) 3�3 - l 16% Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: WAUTCkV fri 691tJ 6' tNC. <br />Address: 54.3 AtsKE W. City: W. Sfi C. Zip:—q5(0171 <br />Phone #: (I i (v ) 313 -11 (Pei <br />Authorized representative of contractor certifying through signature below that the t has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: Tide: _Signa e: 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: CAU COAST MAAyUFAGTQA-I NCS )AIC - <br />Address: 54a W • UN b✓ Ciry: TUILL.00K Zip: q — <br />Phone #: ( Zoo) 68 – R32 > <br />Date Tank Received: <br />Name: <br />Title: <br />Signature: <br />EH 23 046 (Revised 7/10/96) Page 10() <br />Date <br />