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SAN JOAQUL'+ COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> rSECT;ION <br /> 1 - Public Health Services Errvironm,::._al Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Trackir; 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 returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: '7200 cs& rC 5; MAA4M e-A (Skwp <br /> TANK ID #39 - TANK SIZE:__PREVIOUS TANK CONTENTS: t 1►NL@AaDf�2Q <br /> i*rr+++##r#rtWi+rt+firt##wrt++fi#fi##w+f#fifir**�.:n'•r#+fir++rfifi#fi*+rfiirt#+#wwr+++##rrr#firrrrfifi+++fir#wfifiri*fi+r+rrr+firwfi <br /> SECTION 2 - To be filled out by tank remova contractor: �- <br /> Tank Removal Contractorrcil� _ _' =J � 9c <br /> Address: la6R /4,10 "/6'd <_r Ciry:eS�t eckVOA J Zip: 4rZ40Sr- <br /> Phone #: (J� )�L�fL �� Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "c :contaminating tank": <br /> Tank Decontamination <br /> )� Contractor Y t �..a �Sese'etcE. r""ft .J ArF <br /> Address: Ro(? 4L. WA3(04 S-r, City:�D�Tr <br /> Phone p: znz--) 4t 4f R-S93 <br /> Authorized representative of contractor certifyu.._> 3trough 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 au :orized representative of the treatment, storage, or disposal facility <br /> accepting tatilt and/or piping. <br /> Facility Name: CAL <�MA-M- F-1 <br /> Address: q60 /-4, City:�71&t2.4ecck- Zip: F5-T�-C) <br /> Phone H: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> firrtr#'fir#�#++rt#fi#rwi#rrfi#'fir#rt#W*rr#+#�+.�fiWrfi+#rrtrifir##++Wr*#r#r######r#ri##+rrr#rrr+##rrr+r+w#iW#fiirirfi <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />