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SAN J0vmdUIN COUNTY PUBLIC HEALTH SERVI%,/S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> *##w**titwi+r+#ttrtrtti+++trts++rttst+#w***+#kttt#rt*s++«rs#krtrr+«r»+«*4*«r#rrtt+wstw«#kt»«ws«»++ktkw++##twt++ <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 NAME: ! <br /> FACILITY ADDRESS: <br /> TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Conrracto - Urfa /i <br /> Address:t53n <br /> /0Lo z Cit) S ` -\ <br /> Phone N: (meq <br /> G <br /> Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating <br /> Ctaank-": <br /> Tank Decontamination Contractor, "� �/c�� ��- /n�� c' <br /> Address: <br /> KJr� 4 C�, �T City Zip: <br /> Phone #: (— <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: Daze <br /> krrtrts**++k#rtt*»kk#rstw*+r+rtrti+#w«rtwt»#i#w**4»«ttrtit+#rtt*+«»k»tw+#rtt»w4+rri#r*»w++«k*«+«k»44+ktr+«44+#4++* <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or <br /> and/or piping. <br /> Facility Name: <br /> Address: �d V o . ((Q�,/}-C„t�ZI�C�'f—(ZEA City: cool- Zip: �; <br /> Phone N: ( )66& G 37h—' <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ##«*#rt***»*«krt»»4#4«r##trrtai*+rtwi+#«*rtrt#«*»rt«+Birt»4#krktt*»i»»#«**»4+rtart##rtrtirw++«***i+#rtrit+#rii»«r* <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />