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SAN AAUIN COUNTY PUBLIC HEALTH SERV <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 with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days 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: <br />FACILITY <br />TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br />###rt######rt###wrtrtrt#rtrt######«rtrtrtwrt«w#«w«#wrt#««#«rt###rtrtrtrt#rtrtrtwrtwww»»ww*wwwwrt««#»«##rtrt##rtrtrt«ww«w»«»*###rtrt##»»» <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: <br />Phone #: ( ) Date Tank <br />City: <br />Zip: <br />«rtrt««»«ww»«*««*«»«w«»«»»w»#rt####xrt***rt#rt###«x#rt#wx#xrtxrt»»»»»«»«x»»»w««w«««w#«#*#*»»x»»x*w»»«««*#w##rtxx*rt**+ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: City: <br />Phone H: <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: <br />Signature: Date <br />*##rtrt»«««»xwx»»»«»w#rtrtwrt###rt»rt««wwwww#rtrtrt##x#xrtrtxwwrtrtrt«rt»rt»w»»»«»wxww«rt««w««ww###*##rtrtrtrtwrtrt#rtrt#»«w*««#*#rtx# <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 />City: <br />Phone tl: <br />Date Tank Received: <br />Zip: <br />Name: Title: Signature: Date <br />EH 23 046 (Revised 10/19/98) Page 10 <br />