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SAN JOAQUIN COUNTY PUBLIC HEALTH SERYICES <br /> IRON�ENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TR4,C1CNG RECORD <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: OC�VeG4a� Pi SK ^G Qr,Is. <br /> FACILITY ADDRESS: 4/#30 :S. <br /> TANK ID #39 - TANK SIZE:� I� 4PREVIOUS TANK CONTENTS: QP'S <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> CJ- J - <br /> Tank Removal Contractor: - elm L Adm <br /> Address: wism) ! City: <-fk iP�t Zip: / S <br /> Phone .0: (20`3 ) !�66 7 9P 1•C Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Cana-actor: &Jaoue <br /> Address: _C:ry: Zip: <br /> Phone ,i: ( ) <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: <br /> I1Id/.a . , /4 7TE E Title: G�/pe�_Signature: Date <br /> SECTION 4 - To be signed and dazed by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: PVC'siG <br /> C � ,4Aerj1�� <br /> /� <br /> Address: T <br /> 6m �• tot aw7 City: 7&-K60CX- Zip: 7y 1 <br /> Phone R: <br /> Date Tank Received: <br /> Mame: Title: Signanae: Daze <br /> ._=.===a#at====tt=.===_•---___##=*=tat=#a==#......_. _#._.=#==ata=a=.===__._ *#=a##=#=____=#a..t###*##_#_ <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />