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SAN JOAQUIN COUNTYJ *VICES <br />ENVMON?vjENTAL HEALTH DIVISION <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: Qv®1L <br />FACILITY ADDRESS: 2-Z-$S--�'• �''TaG.1�-'`�� ' C �S�S <br />TANK ID #39 -, Doff. TANK SIZE: PREVIOUS TANK CONTENTS:U N�-/® 61 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: WW dt 14 -en rm h Cr+ ^ cc yet"" <br />Address: '�'O 6X d s Ciry:�.l1 Y ."C_ Zip: <br />Phone #: () �'�' a ® ® e,8 S Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: U2,2 Y\ ct <br />Address: PO Q3 PS X 1O , City: GcJ • S �- Zip: %S 6 <br />Phone #: (9) 3 ?_CP <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:—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: UJ E -ST'CoasT r _. u i M Eh <br />Physickl/ 7'v2dc <br />�%- _zip: �75'38b <br />Address: O GU • X i' AiuQQ d _ Ciry: <br />Phone #: ( fi b q ) 666— 23 '78 <br />Date Tank Received: <br />Name: Tide: <br />SignatureDate <br />EH 23 046 (Revised 7/10/96) Page 10 <br />