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SAN JO QUIN COUNTY PUBLIC HEALTH SERVit4S <br /> ENVIRONMENTAL HEALTH DMSION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKDVG RECORD <br /> lrtrtit»##►##itiit4iiii»rt»t#####it*r*r»##it#t#►itiixi*rt#ktti»i»**irt»tV+irrrttiitti#rt*irt»i#ski*www#titii#tt <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 re ed. <br /> t � <br /> FACILITY NAME: <br /> FACILITY ADDRESS: O <br /> IOi000 4acf1 R5� she <br /> TANK ID#39 - TANK SIZE: Iofow. Icn Ian PREVIOUS TANK CONTENTS: [jest <br /> iiirt*i*+*t*t*####rt#»»»+#rtrrt##t#iti*iri*itt+»rr►skit*4t#i#irkittr#iii**rt#i»lir*trrtrt***+tint»rttrttt#trti#r <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> _1 r <br /> Tank Removal Contractor: A d oh NC eA <br /> Address: 4Oa5 N. W t 150 f\ WA City: ST4K T ")on Zip: 570'7 <br /> `? <br /> Phone p: (29 ) h / p O Date Tank Removed: <br /> r*rt+**ti»irt+*rtrt#*»+tr»r**rt***tr**+*«rrrtinti+*ir*irrtrr«rtiit*irtt«*rt++*rt*rtr*t**s«i**trrr*trt*trrttrtrrtt+*irtr <br /> SECTION 3 -To be filled out by contractor "decontaminating/tank": <br /> Tank Decontamination <br /> rContractor: Ad t)A AN Pn <br /> Address:_ / 0 G 7( N• W; 15(-, n Wh `f _- city: cJ <br /> : TaCK�of) Zip: / 2 <br /> Phone k: (22 1) Y 6 7 leo <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 /> itiit»4iiii#ittiitiirttrtr»»#rt»#»»rti*irtrtrtii#tiii#rtiixi*t*rt»»»ititiirt*t*tiirtiitlir#rtkt*t»»#t*rt#ti►tt*#itt*»t <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: 5_p E [ F <br /> Address: �++ . y�� 5_x ^2p3 6 SCiry: Iy f to(K Zip: J�O <br /> Phone k: (205_1 ) — <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> *»ttiii;tkr»rrtr»r»»»iiitiiti###i#tr»»#i#rtrt►kr►ilii*t##»sit#trt*itt*t#rtrttir*r«iii«i#*rtrr#rr*rtirtrtrrtirtrrtr** <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />