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_- - -L <br /> SAN JOAQ COUNTY PUBLIC HEALTH SERVICES <br /> EN )NMENfiAL HEALTH DIVISION <br /> UNDERGROUND S1 _AGE T.LNK DISPOSITION TRACKING RECORD <br /> ###YY######WxW####W WY W+YY Waaw#x#WWWx##M#aa.: -#WYxW WW WYWYY#Y#WW###WxWWx WkW W##x###YW####Y#:#W#W#xxYY#WW####Y#Y <br /> SECTION 1 - Public Health Services Environs Health Division Tank Tracking Sheet snail accompany each tank affixed with <br /> its:site;identification number. The Tank Trac:;. :eet is to be re urned to Public Health Services Environmental Health Division <br /> within,30 days of acceptance of the tank by the osal or recycling facility. The permit holder is responsible for ensuring that <br /> this formiscompleted and returned. <br /> FACILITY NAME: (54X, � 5;',4 <br /> FACILITY ADDRESS: r/'LUD 5&, CX(A.�p <br /> TANK ID #39 - TANK SIZE PREVIOUS TANK CONTENTS: t( 6 <br /> W#W#Wit#W#MM#####MW##W#W##W#WrtWY#M#+V.F+M Wig- -xx#MW WxW YW#WWW#xWW##WW##WWW#Y#WxYxW#xWW#W#Wwax##W##W##WW##MY#xW <br /> SECTION 2 - To be filled out by tank remoyz :tractor: <br /> Tank Removal Contractor, <br /> Address:-4n /vo . �Ut�� Ciry:S��(rp t/ Zip: �fS—ZeSr <br /> Phone#: ate Tanis Removed: <br /> #W##MSW+kWWWMW#W#####WW#YY#WWWWW+4xWWWx#+rx- -!FM#W WMMxxW##WY##+FxWxWxx WW WYxW W#Wrt####x##W WxYax W#W##W###WW####WW <br /> SECTION 3 - To be filled out by contractor itarninating tank": <br /> Tank Decontamination Contractors , S�� y c�-,— <br /> Address:&,? 4"'. W rJton} City:ST-6,4-rrv.J Zip: �e7S— <br /> Phone #: (een — <br /> Authorized renresenta[ive of contractor cenityi; ounh sig^.ature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title-- Signature: Date <br /> ######WM+K#W####Mx##WW#W WM###WWWMW x#x+n W+:. ,..vxW##fiWxxW#WWY##W»�WM#xxW#W#xYWx WYWWWWWWW W#WYWMW WyaWWW###W#x####M <br /> SECTION 4 - To be signed and dated by an at. zed representative of the treatment, storage, or disposal facility <br /> accepting tank and/or pining. <br /> Facility Name: <br /> Address: �00 /ib 1�tCry <br /> !�� c i �r �C) <br /> a r �r2Cac.�L ZZP: <br /> Phone #: (Zpq <br /> Date Tank Received: <br /> Name: - Zine:_ Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />