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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*M --- xxx:ie--W*..... lezx;ez gexxxyexxxxxaelayexiexa�kxxactKKxk Te IexxxxxXxaK ieacaexiez�egeyci:xciexaexxacXxae ycxaeae is <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 />1v <br />TANK ID `39 - TANK SIZE : 3 00 0 PREVIOUS TANK CONTEINTTS: <br />xxx.....x]c.....=*-------------- w­--xxxXxx%XxXxXxM-----XXXX%X-----xXXXaeXXXX Xxxx MXXx XaeXxM Xa[MM MMMMic:e <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />U. a <br />Address: P D • -,.®-4G a 3 G Ciry: Zip: <br />Phone #: (a O Cl ) & ( ? " 13 1 d Date Tank Removed: <br />xXxXxxxx====xxXx-xx..xw*==xXX*x*x:-x=-xxxXxxxMXxxXWx =XxwXx-x-XXxx*x*x-xx-MMxxKxxx,�xx�x�,�x�MXx� <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank: Decontamination Contractor: <br />%ddress:4S3,(:; Zip: 9J�2 <br />Phone?-: (,10 9 ) `%61 - V 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:_ R Title: �4ZL Signarure: Date 90 <br />x:�x��:�x:x�xxx:iexeyeaxxx�eieaasxyexx�exxx�X:exxyeaex�x=xacaer:X�xiexxaexx==XX:xx:xX�:�:xXx:::MXx:::Mxzrex:x:x=XXxxKxXxxx <br />SECTION 4 - To be sinned and dated by an authorized representative of the trearment. storage. or disposal facility <br />accepting tank and/or piping. <br />Facility Name: <br />Address: 7 OO N �,(� �L�:vt U ' City: Zip: <br />Phone : (z 0 Q ) (o & g 7.3 % 8 <br />Date Tank Received: <br />Name: <br />Title: <br />Sisnature: <br />Date <br />yR ae]j[X�RMiei4T[9Lx*]kiCa4[]i[%As �K ak gexaka�e �e**]ie�]efjelk fje �K T�M;[xaeMi[iex3Crie?cfe �e ale �[aeat�FX%e ak 9jCapCx XXA�ii4�CXXkese]kxX:e�KXZXX+K �F ke k��K]It�K*�K��KaK*]KAB]Il1j[IQC�F**NtaRCX�e �K ]I[]I4 <br />EH 23 046 (Revised 9/11/96) Page 10 ^ <br />y f. <br />