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SAN 10AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVM0NNNWffAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> i.//Y/►/#/►/Yrt►arrla!!Y/w#Frtrt#.!lwww##r►rias./s.rr+wrrw+...r/r.#rrr...w...r.....+w+wrwrr./ti..#+#r/r..+/+++ <br /> SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheer shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sheet is to be returned w Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: T t <br /> FACILITY ADDRESS: E Q <br /> TANK ID x'39 - TANK SIZE:il o - PREVIOUS TANK CONTENTS: In Kan wi2h <br /> +.wi...++.r+/,U+r/++++/r#r+ +....s//++++++rr...r..++++r+rtr+r++.......++w..w.....++......W........... <br /> +++.+ii++ <br /> SECTION 2 - To be filled out by <br /> tank removal contractor: <br /> � <br /> Tank Removal Contractor: A Q Kee t Cor&A !'\jG+i no <br /> Address: �� WCST ��+y AvQAve City: � (G(�j Zip: <br /> f <br /> Phone a ( �S_ 3�,-501Q Due Tank Removed: q,Q 19`' <br /> ++w/iwrwa#rrrt/..!!l..wrt##rt+rtffwM.lYYY/r//i...r+wr.ar+,Y,FrF+1+is...#wr.r#....s.s....++rrr/rsswssw++V,r+wr+i+v♦ <br /> SECTION 3 - To be filled our by contractor "decontaminating tank": <br /> Tank Decontamination Couttacror: �)J <br /> Address: Nj City: rV1(L_ _.Zip: N <br /> Phone A: ( ) N <br /> Authorized representative of contractor cerrifyiog through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: N I1A Tide: N I tA- signature: ty/19 Date <br /> .........+.wrrs......+s .........rr+w1+ <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: Tot Lep. <br /> Address: NMU4D City: SToGK#en Zip: 9520 — <br /> Phone N: (7-09 ) <br /> Date Tank Received: 12- Wflmhek 1Ci9 <br /> �(ice <br /> Name: JACK ��H 1 Tide fYfic�iiv! P UFA-Signantre: Daze <br /> .+.++...r......r.../wsrvsr+rtri..s.....w...............*..+++...w..++li.........................+........ <br /> EH 23 046 (Revised 9111196) Page 10 <br /> Z d 21kl L9V 6OZ MMIIAN3039 030NVAGV W02i3 WVSV:6 L661-D0-Zl <br />