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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMMN <br />TAL HEALTH • <br />4,.r,-E-TjtXTrC DISPOSITION TRACKING RE <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: 5AY tS M I1j) rv]Aa*K- <br />FACILITY ADDRESS: 33od WEST LANE 5Z'o cCA 95-210G <br />TANK ID #39 - 3300 --3 TANK SIZE: 000 PREVIOUS TANK CONTENTS: WJL6)0r0fQ &A5 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: RICK WAL.T®Al <br />Address: c) Say( 6025- B-3 P4SL--E (-N City: W. Zip: 15-6171 <br />Phone #: 313 —1162 Date Tank Removed: PF11— <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: WA UTON f!yK51 tJ ET INC' <br />Address: 4343 P -15V -e W • City: Ul• 5A -C• Zip: 15-617/ <br />Phone #: ( `fi ( (o ) 313 -)( 4,2 <br />Authorized representative of contractor certifying through signature below that the <br />manner as required by Cal EPA. <br />Name: ` ► Title: <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: <br />CAL, <br />cDA57 MAA/UF/o+GTUP=INCA <br />ANG• <br />Address: <br />15+o <br />W UN 1 CC(o) <br />City: -r04 ,oC K Zip: q S 3807 <br />Phone #: ( Zo9) 49 R3"3-$ <br />Date Tank Received: <br />Name: Title: <br />Signature: <br />EH 23 046 (Revised 7/10/96) Page 10() <br />Date <br />