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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> a...awawwwawaw.wawaaaaaawwaaww..aa.wala+r..asa..wwawra...a..naw.a.w..aaaw...a.aaaaaaawww.a.a..www..ww....... <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sheet is to be retuned to Public Health Services Environmental 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 isscompleted and returned. <br /> ITY <br /> FACILNAME: l-t cC �y ci S 1-r\ r la 74 <br /> FACILITY ADDRESS: r,--, 'V-CC` 1`r v, j. )0 <br /> TANK M #39 - TANK SIZE: I(�! r?REVI0U5 TANK CONTENTS: <br /> v <br /> rt.w..w.......rt..rtrt..rtww....rtrt.ww.ww..a.rt......rt.rtwww....wwa....rtw.w...www....rt..rt...........rt.............. <br /> SECTION 1 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: �A-c, C . <br /> J 1 <br /> �+ LL <br /> Address: W-7 City: Zip: CI G? <br /> i <br /> Phone .#: Z -Chi Daze Tank Removed: <br /> ....................................rt.ww.....w.w........ww................................................. <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor. - <br /> J I <br /> \A 1 <br /> Address:—L--7 t' IS�:E_ , _ City: rc•CL zip: +<?_ <br /> Phone #: (o- ? ) E <_ r-,'" <br /> Authorized representative of con=.or certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Tide: Signature: Daze <br /> ............................................................................................................ <br /> SECTION 4 - To be signed and dazed by an authorized representative of the treatment, storage, or disposal facility <br /> accepting rank and/or piping. <br /> T i _ <br /> Facility Name: I.t'•' G c^cL� s-C�� : c,� — <br /> a <br /> Address: r-) C ti . 1 11�. n /{�itL Ciry:iu� C:. - Zip: <br /> Phone ,t (_2'`� ) �_<U - C6 c c� l�. 1� X c fYr_ • 1 __\ <br /> Daze Tank Received: <br /> Name: Title: Signature: Daze <br /> ........aa...............a.......w.a.a........................aw.....w................................... <br /> EH 23 046 (Revised 9/11;96) Page 10 <br />