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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 ADDRESS: �7 `� w • Cy (LANT—LIN"� 12 <br />TANK ID #39 - TANK SIZE: % p D C> PREVIOUS TANK CONTENTS: '�6_'_� <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: S <br />Address: y _4JgX� City: LQS I�p N l?J Zip: cj3 <br />Phone #: (`Z 5_) �6 �_� - I S '7 r) Date Tank Removed: <br />*********************************************************************************************************** <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: Ll N e - <br />Address: NO O Ciry: Lo 5 N -, Zip: <br />Phone #: ( Z_nq ) K A,� - \ �7i n <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: <br />Signature: <br />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 />�-T <br />co AST <br />U M e -At <br />Address: _? t) <br />9 N • �_Q <br />L 1\1 61- <br />City:To iz l -O <. K Zip: qsm,p <br />Phone #: (moo 9) 6 � � <br />Date Tank Received: <br />Name: Title: <br />Signature: <br />EH 23 046 (Revised 10/19/98) Page 10 <br />Date <br />