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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> t <br /> SECTION I - Public Health Services Environmental Health Division Tanis 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 recycluig facility The permit holder is responsible for <br /> ensuring that tlus form is completed and returned <br /> FACILITY NAME <br /> l <br /> FACILITY ADDRESS Z 2-1 A-vt <br /> TANK ID #39 - TANK SIZE r Doo o C,,%) PREVIOUS TANK CONTENTS f c5e 1 <br /> SECTION 2 - To be filled out by tank removal contractor <br /> Tank Removal Contractor Z A(.._ tJ C_ <br /> Address .o� s� c� �_ Sti,Lt- qoo City —114c.tiv► �e _ Zip is(A7 <br /> Phone # {�} �y�e '�q�(� Date Tank Removed <br /> SECTION 3 - To be filled out by contractor "decontaminating tank" <br /> Tank Decontamination Contractor <br /> Address City Zip <br /> Phone # <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- Signature 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 r V o <br /> Address ��A✓� �� Vc� City 4 Zip _1q_�ga <br /> Phone # 1?�`1� <br /> Date Tank Received <br /> Name Title Signature Date <br /> EH 23 046 (Revised 9/I1196) Page 10 <br />