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SAN JOAQUIN COUNTY PUBLIC HEALTH S&VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ###+lk+4t4k4Wtttt4rtrttrt#;WWtrt W44rttttrtt4t4rtrt+Wrtrt#itrtrtrtWt}i4tttitkk+#+#kk#M#{krt##ik#kkkkkkkktttititW+##kiilkWt <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. �7 <br /> FACILITY NAME: ,ee?a <br /> FACILITY ADDRESS: <br /> TANK ID k39- TANK SIZE:1 "qL PREVIOUS TANK CONTENTS:S/1Y/O <br /> kkk##irtk}ti#kik#ttiiikikt!#let#Wlttkt#lei+kiitXtXXkk#lkkiikii#X{k##k###}ii+rt!#iXiiii{Wt##tW++###ktiW##k#tifik <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor:-.& <br /> City0&V-A&? Zip: QS + <br /> Phone N: (c," % 02�,Jrt� Date Tank Removed: �— <br /> X##ii#X#Xilittk###kktttt{itttXXXX####tXXkt#+iiXtrt+##}#tkX++k++i##tt##4{++#iXR{#k#rt#k#kkk#title#Wt Wk{X#XkXrt4W <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor:40e) ?e Q <br /> Address:•yL�Sra t✓ /Q-/pNL/46 - �1�� City: r zip: 7 -00 <br /> Phone q: o <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 /> kit#k#t#lei#iklktiikliik#i{{kk#liX;t!#tkXXXiiiXX#rtrtirtXl+likit#likkXXX#kiiitrtlifikk#klit#ikk+iF##i++iXi##!#4i <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 /> Address: City: Zip: <br /> Phone#: ( ) <br /> 'i Date Tank Received: <br /> Name: Title: Signature: Date <br /> k#iy#{i Wrti#let#rt+rttRt#kart#X+#++Wki#WirtXR#rtrtrtRRlrtrt##rtrtXikk+krttlil+let#i#!X#i44#itilrtiirt#!#i#rt+tttRtttt#i#4## <br /> EH 23 046 (Revised 08/13199) Page 10 <br /> I <br /> I <br /> f <br /> II <br /> 1 <br />