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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 Environmenta: 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: <br />FACILITY ADDRESS: �� ( E- I'IGS2vKu tG C�-y e <br />TANK ID #39 - TANK SIZE: I'/. !Q,CV& PREVIOUS TANK CONTENTS: CO"O t WA, t w <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: 066 rtwfa r <br />Address: S%'SLe I 4v" Lit a'k- CL% • City: g k, c f -tr Zip: 95-87-Y <br />Phone lt: ( 41 ke ) 4*2-V ' 7'45 74 Date Tank Removed: i "frWu.k. A)DJ - <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: A, City: S.Lc{-v Zip: 9��Z <br />Phone #: a ) 41-Z 1 V 1 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: Title: Signature: _Date <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />ilft accepting tank and/or piping. <br />Facility Name: H►t� �'* r'� �r 6 t"� • b.1 i-. w ra L t �{- <br />yLt.�,w Gua. <br />Address: 1 DD ( F ala LLwo j C, C City: feWW*,& Zip: <br />Phone <br />Date Tank Received: <br />Name o •�'�a ''� Title: OW►�r Signature: . Date A-4 Zf t . <br />EH 23 046 (Revised 9/11/96) Page 10 - <br />