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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />UNDERGROUNTI) STORAGE TANK DISPOSITION <br />X.... XXyCXXXX]6X%X------xxxXXXXXxXXXxxz.....**.=.... z]C]eCfCiC%XXXXZXXxzzXxzx-----XXXx Xxxxx%XTCXXXXlCX X--XXXxXY ---% <br />SECTION 1 - Public Health Services Environmental Health Division Tanis Tracking Scree; 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 recvciing facility. ine permit holder is responsibie for <br />ensuring that this form is comoleted and returned. <br />FACILITY NAME: <br />FACILITY ADDRESS: q S. <br />TANK ID `39 - <br />0-( <br />TANKSIZE: /Q®D® PREVIOUS TAINK CONTENTS: <br />.XXXxXXXXX-XXXXXXXxXXXXXXXXXXXXXXXXxXXXXX,----XXXxXX----XXxXXXXX-.X-XXXXXXXXXXx-XXXXXXXXX—WXXXXXXXXXXXxXX <br />SECTION 2 - To be tilled out by tank removal contractor: <br />Tani: Removal Contractor: <br />Address: City: Zip: <br />Phone #': ( ) Date Tanis Removed: <br />X*XXXXXXXXXXxXXXxXXXxXXXxx.XXX.xXXXXx%XxXXXXXXMXX#XXX-Xx>rXXXXXXX-XXXXXX------- <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: ,S i(1/1 C1N:%SSD 157 <br />Phone r : ) (o -- ip 33 7 <br />Authorized representative of contractor cer-ifvi a through signature below that the tank has been decomaminated in an apo_ roved <br />manner as reouired by Cal EPA. <br />Name: /�F} j? R /�� / IR Title: ,t Signature: ��' Date <br />%X%%%%XXX%%%XXXXXSXZijfX]ICZ�¢XYXxXXXXXXXXXXxXYXX]i[X%aCYXXXX%sXJCXXXXYXXX%x%yCXXXXXXXXXXx XXX XXXS]jt]jCXXXXXXXX%XXXXXRXX X <br />SECTION 4 - To be signed and dated by an authorized representative of the -"eatmeat, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: <br />Address: <br />Phone <br />Date Tank Received: <br />Name: <br />Title: <br />City: <br />Sisnature: <br />Zip: <br />Date <br />%icz XXX X %x X z %X X X hie ycsiaakatxzzXycrkX XrkXX%xXZXxXX%zxz%XXX%X?�%X%%%%%x X %aae%XX%X %y[xX X xXXx:xxXXXxzak+k#%a�kakaysrles��Ocr�azakauaKkaaecaK <br />EH 23 046 (Revised 9/11/96) <br />Page 10 <br />