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• <br />U <br />SAN JOAQUIN COUNTYHEALTH SERVICES <br />ENVIRONMENTAL .1 DIVISION <br />INTO-) ' '• 1 •' 1 '• t • •�1 <br />*********************************************************************************************************** <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: <br />FACILITY ADDRESS: <br />TANK ID #39 - TANK SIZE: 1 PREVIOUS TANK CONTENTS: <br />*********************************************************************************************************** <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address • City: Zip: <br />Phone #: ( ) Date Tank Removed: <br />SECTION. be • out by t"decontaminating <br />Tank Decontamination Contractor: <br />Address: <br />Phone #: <br />City: <br />Zip: <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: <br />Signature: <br />Date <br />*********************************************************************************************************** <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: <br />Phone #: O <br />Date Tank Received: <br />City: Zip: <br />Name: Title: Signature: <br />Date <br />********************************************************************************************************* <br />EH 23 046 (Revised 5/20/96) Page 10 <br />