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SAN JOAQUIN COUN-rY PUBLIC HEALTH SERIVICES <br />ENVIRONiIfEN'T,k.L, HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACING RECORD <br />xz xzzzzxxzazxxxzxxacx#Xxzzzxzzxzzzxzzxzasxxxaczz#zzxzzzxxxzzxz----xxxzzzzatXxXzxacxxzxzzz#zXz----xxaexxxxzzzxxxxx <br />SECTIO_+ 1 - Public Health Se��ices Environmental Health Division Tanis Tracking Sheet shall accompanv each rani: a:�rxed <br />with its site identification number• the Tank Tracking Sheer is to be reru =ed to Public Health Services=nvIron:.*:ental real_; <br />Division within 30 days o; acceptance of the tank by the disposal or recvciine facility. The pe. *t holder is resDonsloie for <br />e:su_nns that this form is cotnpieted and retuned. <br />FACILI;_ ADDRESS: <br />T_itNK !D <br />0. F <br />TaE SIZE: �;DOO PR: YiOLS ACON--N' <br />__ ,. <br />u <br />.xXxXXXXXXxxXXXxxXxXXXXXaeXxxxxXxXxXxxXxXxXxxxXXxxxXXxxxxXXXxxxaeXXzxxXxxXxXxXxxXxaeXxXXxxXXXXXxXxXXxx------- <br />SECTION e - To be filled out by tank removal contractor: <br />an_•Ic Removal Contractor: W . ZA-A, (� <br />F t� �� a3 � 2 C: <br />Address: V <br />Phone -. �_ 0 9 ) ( 6 � — ?3 7 2 Date Tank R. -_moved: <br />xxxxxxxXXXxxxxXxxxa.X'.696x•A-------------xxXXXX}t-XXxxxXxxxxXxXXXx--Yt IR----xXXXxxXx XxxXx XxxXXX--XXXXaexxxxXA-----as <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tar' Decont�rn"'ation Con�ac:or: <br />Address: <br />Aurhor� -eoresentanTve e contracror siQna7 below at :ani =zs __ . decontarated _ approved <br />:canner. as _ eauir ed by Cal E?A. J <br />acne �R �y�25_72 1 - ' Date /U / <br />:�—r �Titie-� L.P- SiQnatu:-e• 9 <br />XxzxxXaoxacxxx X w-xaezxxXxzXx:xXSX]C----- CXXXXxxXSX%X-------x}exxx`-=xxxxx![--------XXxxx--------=---xx-----xx - <br />----- <br />SECTION 4 - To be signed and dated by an authorized representative of the :7-.=e^t. storage. or disposal 7_2c:lir+ <br />acc=dn; tank and/or piping. <br />r acility Name: <br />7 N v -)Z <br />�.�,u� city: ip: s3 1 <br />Address: Dy <br />phoneT:b /3 % <br />Date Tank Received: <br />Name: <br />Tule: <br />Signarare: <br />Date <br />%zx-X--XxxrexXx]i[xxxxxL6xxx]LXXxX#--------------------------------- ------------Xxz}tz-xX#X#i#------ <br />41-123 <br />ilii# <br />EH?3 046 (Revised 9/11/96) <br />Paze 10 <br />