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C7 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH <br />ENVIRONM:ENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION T' ` li RECORD <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: SAS (s MA M49-KIET <br />FACILITY ADDRESS: 33©t7 WEST LANIF 5Zb c V___rQnJ CA 95Zo� <br />TANK ID #39 - X300 - TANK SIZE:oo® PREVIOUS TANK CONTENTS: V/kJG&-A0fQ &A5 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Rt CK WA L, -TOA) <br />Address: FO 5a)(, L025-, _e*3 R1S��' LN City: W Zip: 956q ) <br />Phone #: (q ( (o ) 3'13 -116'- Date Tank Removed:- 199 <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: WA-LTbeV f5'v6F1tJ£ 1e4k6- <br />Address: 843 AIS W- -city: V), S'4C, Zip: R�(o41 <br />Phone #: (I I (o ) 3 73 -1((Dl <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: 1 <br />Title: Signa —Date—LO, <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: cAL, Gt>t57 1WA?VUF-gGTUP_1A*r I )NC. <br />Address: 1560 W UN I!�M_D City: "r01LL0C-K Zip: q 5-38 <br />Phone #: ( Zo9 ) (P(PS 2321a <br />Date Tank Received: <br />Name: Title: Signature: Date <br />EH 23 046 (Revised 7/10/96) Page 1 ) <br />