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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 ADDRE <br />TANK ID #39 - <br />TANK SIZE:_ /®ODD PREVIOUS TANK CONTENTS: <br />ak ak ak �?���ak ak ae ak ak ak ak ae akak ak ak akak �e ak ak akakak ak ae ek aloe akakak ak ak ak ak ae ak eie ak ie ak ale ak ak ak ak ak ak ak ak ak akak ak ak ak ak ae akakak ak ak ak akak;e ak ac weak ak ae ae ak*�e ale �e�ak leak ak ak*icie ak ak ak ak ak:x5e#ak ak ak ak ie ak <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: <br />Phone #: ( ) Date Tank Removed: <br />City: Zip: <br />�e ak ak=**ak ak 4¢>k>fe akak ak ak ak*ak ak******ak ak ak****ak ak*ieakak ak ak ak *akak ak ak ak ak**M** ***akak ak**kC****Mak**ak ie aR se ie ak ak**ak ak**********Mak ak ak * ak akak weak***fie ak?e <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: $ 3 /1 Ciry: Zip: <br />Phone #: (® )(®f 3 <br />Authorized representative of contractor certifying through signarure below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />WName: ke..S%e R Title: . • _Signature: Date <br />>r ** ak ak � ak ec ak ak *ak � ak ak ak * ak* akak * *ak>icdc ak ## akak �e ak * ak �cakak ale akak ak akar * ak akakakakakak ak ate ae �eicak ie ** akaF*qc *akakak akak ae>k 9eakak ac ak ak>k � ak �cakyFak* ak ak�xeac � * ak ak ak>ie?e ie ie ale ak ** ak � <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 />Faciliry Name: <br />Address: <br />Phone #: ( } <br />Date Tank Received: <br />Name: Title: <br />City: <br />Signature: <br />Zip: <br />Date <br />akak* ak ak>k ak * ale ak ak *>k ak ak ak akak ak ak ak akak>kakak * * * **ak ak* ak akak akak ak akape ak ak aKakaR�e ak>Ie ale ak ak ak>k * #* ak ae ak * aeak>leak ak* *akse ak xc akakakaeakakak ale akakknkakeleek%eaka4sak*ak ak*#ekek�c* ekaYak a(e <br />EH 23 046 (Revised 9/11/96) Page 10 <br />f <br />