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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />akiexxxxxxxxxF,iexae,k sic �cde acaKxie��exx,ezxzx xxacxxxiex niexycae lex xaa iaxxxxxiaacicx eiexxxaexarxakiexiexicxxxxxzae a¢x Nexakxxxxxxxx�e aexxxxieae aezxae ac <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site identification number. Tne 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. e A <br />FACILITY NAME: D� C- I ! V <br />FACILITY ADDRESS: g3 <br />TANK ID ;*39 - TAINK SIZE: /O DOD PREVIOUS TANK CONTENTS: <br />....X* Xxxxx XXXXXajeax X]4.'K}C'----XXDCXXXx xMlFzxasXxscx----*---* % W--:-------a[ajexaeYxx XX xzxat fix zJRxlc---ae----sx}CXX--X?eXXX.. <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: ►4/ l.0� <br />Address: a3 4, `s City: •� Zip: X153 FY <br />Phone,--,: ( 2 D 9 ) & (� ?3 7P Date Tank Removed: <br />Z]jC]iXxXXX xXAcxxXxXx]iLxXx�X X:<xX xxk XacXXat re TC ldeXXzaexxXXX?Kxx>tX xxX XSXieXsx]FYcxxX,ic x2xXaCXXXxXXaCXXa,S X�cXic�XxJ[XXXXXaexxYXxxXiC'X Xx <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. , % V <br />Address:�City: Zip: 9,j ®vim <br />Phone r: (�.� )(o �O 33 <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: YAR�%e <br />-1?_Title: P -4,e,,,6 Signature: Date <br />YxxxXxxxxxxxXxx,xxx�xxxx,�xxxxxxkxxxxxxxxxxxxx;xxxxxxxxMxXx <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tattle and/or piping. <br />Facility Name: <br />Address: r%�� N • W cA�� U City: Zip: 9S-391 <br />Phone 54: (o(o9 — /37 F <br />Date Tank Received: <br />Name: Title: Signature: _Date <br />�qa ieMxMx X�eXaex�pe N¢aexie*aK ae%c �k as �exxekx, aiesae�e ya ie�ie �cx�k ae acx X�cz�cxac aeacyeakak �!cxaFx�.iz,kx:icx X�kxx:ale taczssacszx%K�R�K �K?�K.K*+a,*x*a':�r els ap �*3, �ksieye,pc*xc �{c <br />EH 23 046 (Revised 9/11/96) Page 10 <br />