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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DtSPOSPYION TRAC33NG RECORD <br /> ♦fi###.##i####i###ii#i#i####i#.###iii##i####iitiiiiif#fiiiiiii##iii#iiiiiii####iiiiii#iif#fiii#ii#iii##ii## <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheer shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sheet is to be remmed m Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the disposal or rec/cling faclity. The permit holder is responsible for <br /> easunng that this form isscompleted and rammed. <br /> FACILITY NAME: }' Z-r, L c M t n (rCoZ4 <br /> FACILITY ADDRESS: rM,C 'V--CC` l ry\ 11,;-o <br /> TANK M .#39 - TANK SIZE:f PREVIOUS TANK CONTENTS: GLoY, y\ Q <br /> #..........#...i..i.....i..*...........................#.iii...............i.....M......................... <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: r, r o =v L <br /> Address: l^7 r n \ G < cry- p: G <br /> Phone .#: ( Q C 0 0-7 SC Daze Tank Removed: <br /> ...........#....................#................i...#.........i........................................... <br /> SECTION 3 - To be ailed out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: �iJ��C' �� C-r�^ �'n o•v^'.y.�. CC'S..'.,C=� _�V1 <br /> \ \ <br /> Address: l^� �— IG=' S1r� C:N rc•C Zip: r < / <br /> Phone .#: Cf", — < <br /> Authorized =resentarive of=ulaw.ar c--�tirymg dtrough signanue below that the mnk las been decontaminated in an approved <br /> manner as required by Cal EDA. <br /> name: Tide: Signature: Daze <br /> ........................................................................................................... <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting mak and/or piping. <br /> A <br /> Facility ?lame: 1j,'.o G-7 cL <br /> v <br /> Address: r-)' V ti . �.,.n : lr'�iQ Ctry:�\�A�\C'!'�'t Z:p: <br /> Phone .#: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ...#..##.........................i................#........................................v............ <br /> EH .3 046 (Revised 9/11;96) Page 10 <br />