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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: - 1A)t.5 �c)o 5; <br /> FACILITY ADDRESS: p <br /> TANK ID#39- —TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 1A) e J, T c <br /> Address: 67 _5t/e e f City: 7_1kc- X zip: <br /> Phone#: 0'75'5 Date Tank Removed: <br /> SECTION 3-To be filled out,by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: r)Q I <br /> lb <br /> Address: Cit <br /> y: Zip: <br /> 1 <br /> Phone#: (209 ) 63-10b? <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 P Title: Signature: 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 /> Address: City: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 08/13/99) Page 10 <br />