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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: ' <br />TANK ID #39 - TANK SIZE: J O PREVIOUS TANK CONTENTS: 2 0 N Legd o - <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: /a Gj., i (2. <br />Address: City: a -s-- zip: %63,5 - <br />Phone— <br />Phone #: (`Pc) 7S n,6 - IS -7 n Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: ) S �� Ll N r <br />Address: �, © �� `7 �� City:--SANbS Zip: <br />Phone #: ('?—C)Cl- ° — i S� 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: Signature: 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: W �P—� CO /a„1 1--- Cy o i p m (aZ7 <br />Address: CitylL <br />L P: <br />k Zi _. <br />Phone !#:----- <br />Date Tank Received: <br />Name: <br />Title: <br />Signature: <br />EH 23 046 (Revised 10/19/98) Page 10 <br />Date <br />