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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK DISPOSITION TRACIO:NG RECORD SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: © LM, C F FACILITY ADDRESS: 9 9 3 TANK ID 1`39 - TANK SIZE: Y 000 PREVIOUS TAINK CONTENTS: L.,o M%XXX%Mea%%XXXXX%%%%MMIOt]iC%MXX%XIeXXXxXi�e]CM%%M%%%M%%Y%X%%%seX%aC �je%X%]j6„C]dC%M�KXX%%M�X�j¢Y[MXXMJkM%%MY:%Yt]iC7jc M�lax MiC %i�eX%Xac le Jit l�C )je;i:i SECTION 2 - To be filled out b)- tank removal contractor: Tank Removal Contractor: Phone 1`: (AO 9 ) 6 (o Q - q3 1 Date Tank Removed: %%%a%%%apc*X%%%X%%M+k%X%%%%MMMM%%%%MX%XX%%%MX%M%%%XMMMMai%%M%%%%MMMT%**X%%%%%M%%MA=M%%%%%*XXMXMia�cXMie �eMMMMXie%M%Mae:: SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: V yc� Address:,�� S • 0 , City: Zip: �TS:aOS Phone 1`:t-b(o1 (03.3% Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Name: /4,; R 0 b` e. S 7C /Z Title: p Signature: Date/ /9ff aVe x ek�k •k ye # �k �k * %%X %xe x ek �k �a �e �k x x�M �k ak qe# %X %%%M ye ye M=k �e X%%ae %%%aye %oK %qe ie %eje%�Ie�k%%%�ea�e %M %�k�k?caeM %%%ac %Xie %%�k %%� %� X%>s %%%%ye =a: %%M se %M x sp %ac x SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: �/ ,J�e V Address: ?OO x.I,ti ,� - City: �,e�.�.(e-� Zip: 95'3 Sl Phone 1`: (A09 ) ( 4 ? 9,3 *l F Date Tank Received: Name: Title: Sisnature: Date %%�kMek%%%%%%%%%%%M %*%�k M M %%* %�k %%* M �k %%%� M X * a� %%%%%%%� %* %M %%M* %%%* * %%%* %M �k�K%�K �k %%M * * *%%%* �k�k�k %%� � �K %%%%%%%M M%� M •%% EH 23 046 (Revised 9/11/96) Page 10