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P. I I SAN JOAQUIN COLNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD w wwai.MwMyewM:4r#NawMrtW rt'MW W#MMrt rtrtMWM'M.ww.s.y.r#Mw......p*b*#.ey#+kwaeMMfI1MMMrI M111 y,y(W�Prt'b MWwwwMW MM.MM#M w......,,....Mww/nyr�p SECTION t - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: Le ki j-T n FACILITY ADDRESS: �Q V(c O P-D )-0 b - /5 O-- v ovc� tJ UjL FtyE® TANK ID #39 - -- -'`'�3 TANK SIZE: f�'/�.�� PREVIOUS TANK CONTENTS: 1S-o o V7 ttAj wM rtwMM#A.MW:hW*srtwwww M.pWrtwMw#rtWWwrtM#MWWWM##MMwJf.laMw*:.www ,a,wwwMwWWWyeWw#wrtw#W#wWM#aeMMMMWw#wMMw Mve:e.bww*#.y.yw.e.kM WMM:y SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: ,(/ �l'� AlEa Address' 2-bo� City: 5�9�fGlV zip: % ~ Phone#: ( �Q ) �l _ Date Tank Removed: MM#iwWw.NwWwwwrtwwwwr+pwwwwW w+pwwso yawrtwwrtwwae.kwak.leewltwwwKe h NMM+M Yeww.pwrw.px.w.eiwweew#rde#.h,dMwww.Mww+M hwwwh Y:iWiuww+I+MrNs M'r Mww•w•:v SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: C �.SQY ovi /z tcyu Address: td -M L,m j � City: ju zip: 10AutPhone #: (-140— Authorized horized representative of contractor-ccrtifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Name: Title:_ Signature: Date w w w wwwwxcw w w M tlrwep+ww W wwwxa rt r+hwx,.M+ro+esle.k.h+krM.d.wlek+lt kt�e 5h ih yr�t to wiMx+Y+s+h+MM.M w+aaaw+.lrmfnk.Ininfefuk.khAuk Ailsflt Ns+N w wwww w werw w qe w+M ww+M+ru+P�nk+#to w w Yt(e:p m SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: L t, Z. Address: Z Ste- / AOK 131 Vbe City: p-/C fv J'D Zip: Phone#: �)_ 2-jU—, 1,3 Date Tank Received: Name: Title: Signature: Date rt w w#Mw w.eu.#w+e.ses.+M.ta+ke.oenie�e de 4ww+N W Iewnit Ke+lt+k dt 41 dt W ye p1 w w w FM.M.M.Mirww+tAi.MpnMdew.a wr#e.lew+lsltMtde de+kNwkt%cM1�t**w k1+M F Koynpt w w MN+Nw a w w w#QIP M M dl#w Mt Rw w EH 23 046 (Revised 08/13/99) Page 10