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SA -N JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />F.:'VVIRONMENTA.L HEALTH DIVISION <br />UNI MERGROUND STORAGE TANK DISPOSITION TRACT NG RECORD <br />.......%XXXXXXXMXICXXXXXXXXxxXxXX Xx XX Xx XXMakXMXlCXXXxxXXXaXsieXMXXW XXXXX]kacs[]IeXXX......... Ci * .. SX XxxX hex%%XxXM]Ieae Yei <br />SECTIO, -N 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site identification number. The Tanis Tracking Spee: is to be returned to Pubiic -Health Services Environmental Health <br />Division within 30 days of acceptance of the mr-k by the disposal or recycling facility. The permit holder is responsibie for <br />ensuring that this form is compieted and returned. <br />FACILITY NAME: 0 F IU <br />ACILI T Y ADDRESS: l 7-3 �L clS33lo <br />TANK ID =S9 - T:-�-N-K SLE: DO O PREVIOUS T NK CONTENTS: <br />----------- %%%%%%XX%%%%s %X X%%%----------------------- --------------------------------- w ---------- <br />SE CTION- <br />X%%s%---- <br />SECTION e - To be ailed out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: <br />Phone ( ) Date Tank Removed: <br />Citi - <br />------------------------------ * .... *.w .... M -------------------------- --w ------ w -=W.* ------------------- <br />SECTION 3 - To be ailed our by contractor "decontaminating tank": <br />Tank Deconramination Contractor: C IV <br />Address: s- LJ Cry Zip: _Zip: QST. a 5' <br />Phone =. ( 0 Q ) 4(e / — &.32 2 <br />Authorized representative or contractor certifying through signarure below that the tank gas bee. decontaminated in an approved <br />manner. as recuired by Cal EPA. <br />Name: H Pq I? V / /p S '�2 �� Title: Pa Signantre:Date � 9� <br />x xx xXxxXae....Xx%XXT'XXsX>rx XXXXMXSX XM XXXXXMM-----a4MXXXX:4Xi4xxx X9,ezXXXX aXXXaKX?Caje aeieXXSX MMak.....X%xxX�eX MxXxx <br />SECTION 4 - To be signed and dated by an authorized representative of :he treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: <br />Address: <br />Phone #r: ( ) <br />Dare Tank Received: <br />Name: Title: <br />City: <br />Signature: <br />Zip: <br />Date <br />JeXXXx%XXXMxXX XX xX Mx XXxXXxXXasxXXXXXM MMXXXx Xx MxX MMXXXx XaieXXXXXaeaeMXX%XXXX%XXXXXXZMMX XakXMMMMMaKMela:a's=MMMMakM MakMM <br />EH 23 046 (Revised 9/11/96) Page 10 <br />