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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENYII20NI (ENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1-Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany eacif 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 dam 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: 3 (2 G j� <br /> FACILITY ADDRESS: 18-1a ('.t L-t7-Y Ay:t:D h'c AL1 0 Ni (� <br /> TANK ID#39- TANK SIZE: ' 0 6hki . PREVIOUS TANK CONTENTS:/ j� Z <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: t G2 <br /> Address: . <br /> City: P 16¢-(LIONQ Zip:---']4 eo <br /> Phone#: (-570 )X28 5 - j3q3 Date Tank Removed: <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: tw <br /> Address: �'� (��i'`� &HiCA-Glo tf16?ff <br /> `1® City: 6O rt.P COM-0 Zip:_ <br /> Phone#: <br /> a <br /> j Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> !f manner as required by Cal EPA. <br /> IName: 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: P-A'r—/Z <br /> City: P6R"0q,0 zip: <br /> Phone <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 08/23/99) Page 10 <br />