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SAN JOAQULN COUNTY PUBLIC HEATH SERVICES <br />ENti�ZONMEiN7 A.L HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACMNG RECORD <br />SECTION 1 - P�fbiic Health Se -vices Envira=,: tai :Health Division Tanis Tracking Sheet suaii acco=zr-}, each tank a--- <br />with <br />;with its site identification nUMDer. The Tank T raci:Ing Shee: is to be re^; �ned to -rVbHc -z"1=1 ---r, Se"vic_s _zviro==:al _^_ealtn <br />Division Within 30 days of acceptance of the ta--�v, oy the disposal or recycyg faciiiry. The oe..-mit bolder, is responsibie for <br />enuring that this form is compieted and•retu —med. <br />pACIL TY ?�A=: <br />=ACI_TY = JDA SS: <br />I e N7K TiD --*'-z , - <br />T� t� $I`= 3 O0 G P?Z= V10LS T -N -K CONT <br />SECTION '_ - Tc be filled out by tank removal conrmcror: <br />Tzn3k Removal Ccn=-.07. <br />Address: P.0 0-3G `2 3 G 9 U 4 City- __ r7 S� <br />Phone F. (a o 2 ) (n 14 0 — to 3 .7 91 Date l aak R_=ove,.•. <br />SECTION 3 - _ c be fined out by cont:a�ctor�"decontaminating tank": <br />Tan_K Decd . anon Contactor: I V <br />?hone =: (2:0 q L4(a - (.• 3 3 7 <br />-UMOM ed _eoresentative of cont-ac:or ce..if`=mg MrOU= siznar= below :hat me :=k has been decon-L—iaated _ an approved <br />m ^er as by Cal EPA. <br />Name )44 R�% C �-7 e 2 Title: Cil f �1f.+� Si�narare Date `- lly ly <br />� T� <br />x----------------------------------------------------------------=----------.xz--------max-------=---------- <br />SECTION 4 - To be signed and dated by an authorized representative of the storage. or disposal LCH1ity <br />_c:=tn; tank and/or piping. <br />3C11IN �T2�e: <br />Address: 7 oO �( d���tl U ` Ciry:-=; Zip: <br />PhoneT:(zoQ ) (x,&0 7378 <br />Date Tanis Received: <br />Name: <br />Title: <br />Sia*_aa re: <br />Date <br />-------------------------- ------------------------------------------ z----------W-W=--aW ...zzz:s: <br />LH 23 046 (Revised 9/11196) Page 10 _ <br />