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SAN JWAQUIN COUNTY PUBLIC HEALTH SERMES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 returned. <br />FACILITY NAME: (2/7-y 0 ,r� %g -A C i Q U 1 C K <br />FACILITY ADDRESS: 3 6 8 E. // I h 5T <br />C y CA 95376 <br />TANK ID #39 - TANK SIZE: 300 GAL. PREVIOUS TANK CONTENTS: G7gSo L In/c <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: W R 1 Gy M T FN V i F_O N Ml l= NT A L SE/Z_V / C E -S , Zrt C <br />Address: 70 7 F, // /'/t ST , So/TE /021> City: r9AC Y Zip: 9S-3 74 <br />Phone #: ( 11, ) 933 — e) 7_5-9 Date Tank Removed <br />#tYY####Y#t#########Y##Y###k#Y#Ykk###k#YYY#t#Y#####YYY#######################Y#######++#####+##++####+###k# <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: VJRSG#) !li Yl/A <br />y 61 <br />/��'C� y7�` • /���j/ <br />Address: / E City: �s y Zip: <br />Phone #: (_QO 233-075e <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: <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: <br />,JtSi COA5- <br />++ //��11 v <br />Address: /�yu `�� . //�}y ;��a) & City:,-,-- <br />ity: U &c _Zip: -953& <br />Phone #: ( ) lD� `7 37 <br />Date Tank <br />Name: Title: Signature: Date <br />EH 23 046 (Revised 10/19/98) Page 10 <br />