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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVEPONNIENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD 44Vt++tai4ktatR###iitrti#+k+ilii V+ir+i#rtYr#;i#rt+rtrt#a#a}rtkt#rt;i+#ttrtirtrt;irti#rt;i++#art4####rtk;#4#a+*;#ii+*#4i+ SECTION 1- Public Health Services Environmental Health Division Tank Tracking Sheet shalt accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: Pam i+A_ pf-'A" FACILITY ADDRESS: Cq jaQ- 1. G b TANK ID#39- _TANK SIZE: PREVIOUS TANK CO ENTS: N ;i;+i++;akiai#;#ii#RY#+##+i#+t#R##iR#kR}iirtrtrt*V#V##titrt#ttrt4#tttii##rRika#ii4iit+Wik#*V##t;+ia#*i;+#aiiiRart SECTION 2-To be filled out by tank removal contractor: Tank Removal Contractor:_ VCL VLA j�,N�I"k1 ( I� q� Address: 't(/ �q� Lu.c2YV� City: =srA. zip: f7 3 Phone k: ( ( 1) I' (D �ad Iq Date Tank Removed: rtr+*ttrti}krtt#+R+*ta#tk+V###a*i+#Yi;Wt+;#kkV##;rtrt+it#iia;*tt#*iR++#rt++##+aWk#+#ii##iai+#V+tR#+krt4+tut+i*ti+* SECTION 3-To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: AMtrfcvw VOL Iley w&S*e- Q" Address:C t U , fL7�9-2>q b City:_ �1` I Zip: q 5 315- Phone#: (�) `-J?�i�A - Cl�0 "l5 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. iL.)Lk Name: Title: Signature: Date ' rt#ikikit4»»>#4#tit14#>Mt»ti##+ik+##+4##i4#iiVi#iRV+i4tt#t4itiY4+ii4WiR#+Wt#i*#+#R##;riiti++i+tit++aRt++i SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. FacilityName: W eS* Cotxs+ ��lthert Address: IS 90 L3, !_i Vlyr ,A)60 �V� City: ?vC 4 O'IC zip: 95 :M Phone U: (�Z) 6(o -3 - a 37 3 �cD�ate Tank Received: lvame: Title: Signature: Date trt+ttartaa#Cita*tt4+tttr+ri#ia+tut+###rt+rtrt}i+#tiiii+*#++rtkt;#rt+#iata#++ia*kit+4r*rt#+++R+t+#at#;rutMit;t#i+ EH 23 046 (Revised 08/13/99) ` (Page 10 i