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SAN AQUIN COUNTY PUBLIC HEALTH SER*CES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> #»##i##WirtY#Yrtrt#iirtrtfirti###Wirtrtw#4Wirt+#i*»Wt+##Yi W4#i#Yi#iW»#rtrt+4#+rtii#rti#ti+Y##i###WiY»rt#+###4ii#»WrtYrt»W»i <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. l c C <br /> FACILITYNAME:� /D�� <br /> FACILITY ADDRESS: 5690 <br /> � 726%C 4 <br /> J <br /> TANK ID#39 - TANK SIZE: CJD PREVIOUS TANK CONTENTS: �41)10CVW <br /> ##4»w###Yi#4i*WWrtw#»rtrt##itY#ii»+rtY#iYY+»rt++iW#iWWrt#ii#iW»i#i##+i*#»rt+#rti##rti»iWi#W»rti#Y#Y»YY»#tY#»»Y*Wiirrt# <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contraacttor._07.- ') /�/_j��QV Q/z 14c <br /> Address: �_3 GV•/ G/C!`/�r1/ City: zeo/ zip: <br /> Phone#: (�CJ /, �3 �� Date Tank Removed: <br /> ##»##rt*rti#*Yrt##i#»rt##Y#trt**WW*ii#i++###»itrtirt#ii#iiirtt4#i*#i*rtt+rt#*+rt*rt*Wirt######*##*4w#**YW#+ittt#4#tW#t*+ <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor. J/a� ,��� <br /> Address: /� L �/�l�f� l <br /> city: e!:�P/�;/ zip: 95 -A <br /> Phone#: ( ,�O�) <br /> Authorized representative of contractor certifying through signature below that the t yenon[ ated in an approved <br /> manner as required by Cal EPA. <br /> Name• / Title: £ r �✓ 1 Signature: Date <br /> »#rt#YWW#rtrt»Yrt#rt##»rt###Y»rtrt#YWwYwrtR#iY»rtrt##i***lit#rt+ti##4»»*»*# ##i* »i►rttrt# Y### #ilii#Y»»i*Y»i»r##rtrtrtrt <br /> SECTION 4-To be signed and dated by an authorized representative of the tre ent, st1rage, or disposal facility <br /> accepting tank and/or piping. { / <br /> Facility Name:__,5%C111/1 /2—;- r'!Z �^� 7!L <br /> Address: �� e r�� 6� City:AJor// /p Zip: r/ 4 2— <br /> Phone#:W-4—) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> irt###rtw#rtliiiiii»rtllYY»rt#iitYrtwYY#irtWl#wiiY#YY»liiirtrt»rt##i#RiW#WWrtrt*+#rt#Y#r+##+i##4##1#i#iYWYYlw4i#iiiii* <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />