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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ' ENvlR0NNjffNTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACIONG 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 Enviroomeural 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: F'A-c 1 F I G P,JE1-L— <br /> FACILITY ADDRESS: -7-7 1 -7 SOUTH E�-M 45T, F=REf-le-�4 CAME CSTaGK:-r <br /> TANK ID#39- 807 TANK SIZE:Z, CSO 111. PREVIOUS TANK CONTENTS: D I E SF—r �- <br /> ' SECTION Z -To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Z5 1l/Zel7A7ti>i�� S S G <br /> tAddress: 32A 3 11 C/U/tC1 City:{�i✓1ir) �rc�i Zip: /J� � -- <br /> ' Phone 4: ( /�(o) Ly���1+'� Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> ' Tank Decontamination Contractor: EC-1 <br /> Address: Z55S' PARR E50UI-.F—= VAADCiry: Rt °( 11✓ JD Zip: 9480/ <br /> Phone T: <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: Signature: Date <br /> ' SECTION 4 -To be signed and dared by an authorized representative of the rrearment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: F C` I <br /> Address: <br /> MS'S PA-RP,- &0UL4—= V1+-KD City: (Z14�-Hynt,0i4a Zip: 9480 r <br /> Phone.;: ( SIO ) 23S 13� 3 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH Zi 046 (Revised 08/13/99) Page 10 <br />