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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONNMNTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> .rtrtvrt.rtrtrtrtwrtrt..rtrtwwrt.rtrtwwrwr.rww»rrrt..wrtwrrw+r+rtrwrtrtwwwrtrtww.►rr.rtw.rtw..rtrtwr.rtrtrtwww....rtrt.rtwrt...*.......... <br /> SECTION 1 - Public Health Services Envimnmemai Health Division Tank Trdeking Sheet shall accompany each tank affixed <br /> with its site identifinuon number. The Tank Tracking Sheet is to be remmed to Public Health Services Environmeatal Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and tenoned. <br /> n \ <br /> FACII_ITY NAME: a-c-C:� t i1 n <br /> FACILITY ADDRESS: S %¢C` E_c 1 r\r, C'^ <br /> TANK M 439 - TANK SIZE: DCN PREVIOUS TANK CONTENTS: e_ <br /> �- callc r <br /> ............................w ............*.... ....v..........................o..v..v.............. <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> v <br /> Address: (^7 tom"' i Dy\� C-�C"c e. City: Z:p: r-- <br /> I <br /> Phone ,#: ( QCC' --1, -C7,c7S Date Tank Removed: <br /> ........................................................................................................... <br /> SECTION 3 - To be filled aut by contractor "decontaminating t=W': <br /> Tank Decontaminarion Contractor: �J. ^�C' �� `r` hn,o ��'-3 � C�='�.!i C•-Q- , -V_•,_ <br /> �1, J <br /> Address: h-7 �- (U\\ Ste[ ' -24- C:N: cc_U ZD: r <� / <br /> I <br /> Phone ,f: (o r9 <br /> Authorized representative of contractor c.-mrymg through sigaamre below :hat the tank has been decontaminated ;n an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Daze <br /> ........................................................................................................... <br /> SECTION 3 - To be signed and da[ed by an authorized representarive of the ueatme.u, storage• or disposal -ac-diry <br /> acc.-pring tank and/or piping. <br /> n r <br /> Facliry Name: 1,k <br /> �,•� � T t 0.� ` -� ^ ;�• — <br /> u <br /> Address: G ti . t -'n ,n : F ti� Ciry:' elm Z:p:Phone P LJ <br /> ^ � � c <br /> Date Tank Received: <br /> Name: Tide: Signantre: Date <br /> ......................................................................................................... <br /> Ei Z3 046 (Revised 9/11!96) Page 10 <br />