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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> *#*####*##**##*#*#***####*###*#****#*##**#**##*#***#*#*#*##**##*###*#****###*#*##*#####*#####*############# <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sheet is to be returned to 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: tJ/p <br /> FACILITY ADDRESS: <br /> TANK IDD #39 -- ` TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be ft ed out by t k removal contractor: <br /> Tank Removal Contractor: N/A <br /> Address: <br /> City: Zip: <br /> Phone N: ( ) Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: N/A <br /> Address: <br /> City: Zip: <br /> Phone q: ( ) <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: N/A <br /> Address: <br /> City: Zip: <br /> Phone A: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ######################################################################################################### <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />