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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH )DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING 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: <br />FACILITY ADDRESS: (CGOLi e C ib <br />TANK ID #39 - TANK SIZE: �20�TPREVIOUS TANK CONTENTS: Z N25- <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: /T� <br />cj� C Z% City: S16N� t4(LL zip: q0 go <br />Address: �a <br />Phone #: S 8Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: &op <br />�O <br />Address: r3c�X S City; T��t}-ice zip: �-153/G <br />Phone #: Z ' �?IU <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:' CC�+'�T c) r p��^1 <br />-rz��z�©cic Zip:95381 <br />Address: R o �sOx 2368 City i <br />Phone #: (� 6 �0 9 ? -3 <br />Date Tank Received: <br />Name: <br />Title: Signature: Date <br />EH 23 046 (Revised 9/11/96) Page 10 <br />