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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Er'VMONMErTA.L HEALTH DMSION <br /> UNDERGROUND STORAGE TANK DMOSITION TRACKING RECORD <br /> sr.rsssrr.srtrrr*srrwwrrrMss.ssssssrrrrrsssrr�sr..rswsssrrrrrrr.rrrw.sss.ssssswsrsrwwsssrssssrrwwrs.rr.r..rr <br /> SECTION 1 - Public Health Serviccs Environmental Health Division Tank Tracking Sbeet shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sbert is to be returned to Public Health Services Environutental Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling fact ity. The permit holder is responsible for <br /> ensuring that this form is completed and ren=e:d. <br /> FACILITY NAME: A� — A Y T- <br /> FACILITY ADDRESS: 3 ) 33 W. Ad A rY Aoad, 5 ) 0 C V 011 <br /> TIv'K M A39 - TANK SIZE:_3100 0 qg 1 PREVIOUS TANK CONTEXTS: <br /> w.rrtYr.�rrs.r.r..rtes..r...r.rrwrtr..*rrwr.r�r*.rww..r:ss■srr.a.rtesrts.rssswrrsrr.YYrrrwrr...rrr.rswswrr.Y.a.s <br /> SEC'T'ION 3 - To be filled ou``t by tank re�ov� cantractar. <br /> Tank Removal Contractor: 11 V a m f-eLeo v; Kom m-tw d l i H C - <br /> Address: 4 00 5 IV, lei j 50 ri WL-A�! _ City: S T o cO O h Zip: q 510 tj _ <br /> Pbone ": b 7 - 1 DO 6 Date Tmak Removed: <br /> ..ir.a.......a.........rr.rrrrw.".......r....rtww.rrrarrrrrrr....r....Yrrt..w.....................YY warm..... <br /> SECTION 3 - To be filled out by contractor "decontaminating t=k": <br /> Tank Decontamination Contractor: A q va K c + ao g N vii 1A 0 rt?j H ya j 4 'r <br /> Address: 400 � RI. Wi 1san wct�, city: 570eK16P1 zip: g5A05~ <br /> Prone ,': { '�O ) q6 -7 - 1006 <br /> Authorized representative of contractor c_—.frying through signature below that the tank has been decontam-irated in an approved <br /> manner as required by Cal EPA. <br /> Name: �+�t►ik M `14�b +"1 Title: Saq►6r Sy.Sf ,oho }�ti5i an:xe: wt- Date <br /> Y Yrrrar.rr.rtrrrr.aw.wr.rr.r.rrw.w..r.....wirr.m....rrY.r.rr...rY0....rYrY.fY.fkr.l..rr......warr.lkr.m ....... <br /> SECTION 4 - To be signed and dated by an autborized representative of the trey tment, storage, or disposaI facility <br /> accepting tank and/or piping. <br /> Facility Name: WA S T c o a s <br /> Address: 5100 T4y_10Y-_ Court- " <br /> ourt- " City: Tur- )OC K zip: q S3? 1 <br /> Phone 1: <br /> Date Tank R tivcd: "` je <br /> ?Fame: Title: A 4d Signator Date �--azfT <br /> ..rwrrwsrrtrrr.rerr...rmr.......a.........*.**.r.....rare..r......w.sr.rr.r.rrrrrrrrss..ww.r"am........... <br /> EH 23 046 (Revised 9111196) Page 10 <br />