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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <br />UNDERGROUND STORAGE <br />DISPOSITION TRACkMNG <br />s. ..R ' <br />ak ae* akakak * ak #a ak aKak M x a akakakak aRak ak akakak xakakakxakxaKakakM aleck x akakak M 7eakak akak akakakak xak ak %akxxakakakxMak akx%xxakak akxx xx ak ak #ak ke akakakak * akakakMx xak x MMak M akx Makae x ae % <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: D C <br />FACILITY ADDRESS: 9 9 3 <br />TANK ID #39 - <br />TANK SIZE: q o 0 0 PREVIOUS TANK CONTENTS: 4MA A A,Ql,,6 <br />akM%ae ak ak>i%akMa'c Mae--Makak==akMxakajeMMMx XXx xxx Makaie MMMseMM x%Mxakx?c%xxai-**---xMMxak ale%XakXXai Majc%X%MacakMMM%XXMakak%MaxxxM%%%M Mak ak xie ac <br />SECTION 2 - T o be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: a_&n(, 023 (6 g, City: ']'] ,�. ,t/Z zip: -9 -5- 3 8 / <br />Phone n: ( A 9 ) 6 (o Q – 13 18 Date Tank Removed: <br />ak ak ak a.e>k�ak ac aka: akMMxak akakak NeMakak ak ak akxMakaK ak aksexae akM%e!e akxiaMMye�FM�%>k�kx�k%icMMak�kxxzaxak�ksk�pex XM•FxXMMxxxa��k �!a>k�k:k*M��x M�rc�kx�xx M��k ale ie?e#�dcMMxx <br />SECTION 3 - To be tilled out by contractor "decontaminating tank": } <br />Tank Decontamination Contractor: C % �% (T✓LG� ° <br />Address: �S �S ° OA. City: a -y, Zip: <br />Phone"': ( o q) Lb(o "' (P,3-37 <br />Authorized representative of contractor certiryina through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: /}� (? f Z� �� S %E /? Title: Sianature: Date!Jllql9ff <br />ak?eakak ak>k akXc ak � akak ak:kak leak ak ak * ak ak akakak* � a!e qe ak:k ale M ak * gcak ye ak ak ak akak>kakak ak akak akakaie � �e ae ak>Oc�kak ak ak akak * M akakgeakakai ak ak pie: � x x ae M pie �e a� �rc # M� �k de ie=F ale xie x M �e se �e x ie x M �;c �k �e ac •i <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 />n I p // <br />Address: 700 Nj . LCity: Z,41 ? Zip: 9S'3s1l <br />Phone n: (ao9 )� G 9— 9 3 b" <br />Date Tank Received: <br />Name: Title: Sienature: Date <br />* akak ak aleck ie akak ye ak ak ak ak ak akak ak akak ak ak ak ak ak akaK * ak ak ak ak ak ak ak akge ak ak ak ale akak * akak weak ak ak ale ak M ak>k ak ak ak ak ae akak ak ak ak ak #ak akakak ak ak akM vt ak ak * ak M ak ak aleaie * ak ak ak ak ak ae M>t ak ak at ak aloe ajc � M ak x <br />EH 23 046 (Revised 9/11/96) Paae 10 <br />