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• <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACIONG 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 Environmental 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: WI� Vri�r �licv�-c...� I w <br />FACILITY ADDRESS: IOU ( �_ 4GS-�vKt Vt 6W g <br />TANK ID #39 - <br />TANK SIZE: 3 Lp,WO PREVIOUS TANK CONTENTS. (��-5 (- rw <br />r - <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: i42,r 6,4- 1 race e I be e, <br />Address: Geo, t- GL - City: <br />Zip: 45-87- Y <br />Phone #: ( 41 k* ) 41-1- s 7,4 7, !S( Date Tank Removed: 17' a 161%jet k. A)o,s <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: 6.6 i�- <br />Address: �d�[,t► r �oH-K � C-Pt.4f-r- Al - City: Sax. Fv Zip: <br />Phone #: ( jt1p ) 47- s Z V Z Sr <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: <br />Title: <br />Signature: <br />Date <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: <br />lam, v,4, tr. 10-t 'r, c1 � K G l C;, <br />Address: 1 W & i-GwL` �e. &v t City <br />Phone #: ()-V 41' ) ;-3 Y ` & S2� <br />Date Tank Received: <br />Zip <br />Igo,-; 40 <br />Name-F,P6.&'a+ + Title: QWga, Signature _Date 19`4- <br />EH 23 046 (Revised 9/11/96) Page 10 <br />