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Ll <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING 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: <br />FACILITY ADDRESS: <br />�i►W <br />TANK ID #39 - <br />I <br />TANK SIZE: 4 no O PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: <br />Phone #: ( ) <br />Date Tank Removed: <br />City: <br />Zip: <br />***********************max �xx�*�,�******�***************�** ��****�******�x�*x*x�x*�*�****�****�************_* <br />SECTION 3 - To be tilled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: f V <br />Address: AS 2 g U) I✓✓1 City: Zip: 95.20 <br />Phone #: (,2 0 5) 4(o f — &,3.3 <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: /,"e//! 5 % lZ Title: Signature: Date q /9'? <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 />Address: City: <br />Phone #: ( ) <br />Date Tank Received: <br />Name: Title: Signature: <br />Zip: <br />Date <br />EH 23 046 (Revised 9/11/96) Page 10 <br />a , <br />