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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION I - 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 1ZA f1i I I N P R� <br />TANK ID #39 - TANK SIZE:, �� tfj PREVIOUS TANK CONTENTS:zq U m Leoq z4 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: f <br />Address: to • O •px City:LOS &NZ�S Zip: <br />Phone #: (�_) MIL- `E�7 0 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: IL <br />Address: pCity: Zip: -9,3 � 3-1� <br />Phone #: (-�-O% 5< Al - I A % <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: W9S-C LOA;fi U T Q _M - - <br />Address: Q (� �. W �� N l� ` City: 1 O \ O c�� Zip: <br />Phone #: a0<1 <br />Date Tank Received: <br />Name: Title: <br />Signature: <br />EH 23 046 (Revised 10/19/98) Page 10 <br />Date <br />