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3-01-1999 2:d6PM FROM P.11 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />N/A CLOSURE IN PLACE <br />rrWrrnrrwrrrwrnwwsswswwsaswv>+Wan.a+sr}bsrs}swrrrrws>wrav<fwasrrrrrlwsrwrsrwrwrsr>srwssr>wss W>rrryyrrrrrsrr <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 <br />FACILITY <br />TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br />ssssrszsssassrss:assssss:ssrrrarsaeirssssssrasassrss>Ors}srssarrWwss+wrt]r>srswnllWrW»ra�»rtrsrrsss�+>+ssswsrtsrt <br />SECTION Z - To be filled out by tank removal contractor. <br />Tank Removal <br />Address: <br />Phone ft: <br />Date Tank Removed: <br />City: <br />rwrr>r»wwar>rnrr>r>attrrV>wr.r>wra.WW*>r..Wrr»rrrrrrsrv>r>ras:a>rr>W>:>:>svRarWwrr»rrww}rrtWwrw r>s>rrr»> <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />M <br />Phone N: (__� <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated ui an approved <br />maturer as required by Cal EPA. <br />Name: Tile: Signature: Date <br />>lWTrtWrw+uk>l+rtW>W>#+rwr»>ss+sasrs:ss>saa>r»sas>ss>as>ssassrr:arm>s....sasas»>rrtr>}>}}}W Wwwr}rMr<rs>s <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: Ciry: Zip: <br />Phone N: <br />Date Tank <br />Name: Title: Sigmm=: Date <br />rsr;»»ara>ssaau»»»rtW+rtrlW#WlrrtWwrlWrrTWWlrr WWrrW»rt!»!W#rWSMrrr#+>rtwaW}WAW#W}Wwrt#Wrl Ww}rrrrra»»s <br />EH 23 046 (Revised 10/19/98) Page 10 <br />MAR 01 '99 14:56 PRuE.11 <br />