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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> xW+**x*+x*W**x+xxx#x**#r*xxxxxxrtxx*#*+*xx*x*xx#+W#+rt**+++xxW*+xx**+*x#**x*+x#++**#WW#++xxrt****+xxx******#** <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: Q / ii <br /> FACILITY ADDRESS: Z FY9 . 5-o F1 QOra�o �To <br /> TANK ID #39 - Ti4 ZS W0/ TANK SIZE:/O 9 64 PREVIOUS TANK CONTENTS: Qlesel <br /> *+xx*+**+xx*xxx**xxxxx*x##Wx#x#*+xx*xx****x#++xx**+#xx*x*#*xx**+xx*+*xx#++x*+*xxx***rtx#*++**x+WWx*xxxxx*#x+ <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: IVI- A <br /> Address: City: Zip: <br /> Phone#: (_ ) Date Tank Removed: <br /> i <br /> i <br /> #***#rtx*#+Wxx+rtWxW#++WWx**x+x+W***##*xx**+**x#*#+xxx**++*+*****+*x*++*xxx*++xxx****+++xxx**+++****x*#++xrtxx <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: 4 <br /> Address: 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: Date <br /> ##+xxx**rtxxx+xxx++rtrt*xWx*x+#+x+x#*#*+++rx**+++xW*#x**++++WxW*++*WW++#x#Wrtxxx#*++xxx**#**#++*xxx*+++**##rt*xx <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: 'Al 11400-- <br /> Address: City: Zip: <br /> Phone #: (� <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> Wxxxx#+++Wrtx#F+rt##+►WW###rtW#xx#+rtrtWx*W#####xiirtirt##rtrtrt##4WxrtW#x###rtrt#####rtWWxxi#x*W#######++WWxWx##++Wx## <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />