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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD SECTION 1 - Public Health Services Environmental Health Division Tank Tricking Sheet shall 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: ��/ OOAv� FACILITY ADDRESS: J 7'11 /6' .,37— wr jF ' f /7 W ✓ TANK ID #39 - IT02. — Od TANK SIZE: *4000 PREVIOUS TANK CONTENTS:eomLt 5cwe SECTION 2 - To be Filled outbytank removal contractor: Tank Removal Contractor: �J —4c �6r►S'Ir�u ��rr1%� 4P. Address: W2/. -i LAMAIvE Awe -4 2/3 City:5Tj4�;&� Zip: Phone #: (24?f—) 'G.i "d�©� Date Tank Removed: Q, -2/O ########################################################################################################### SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: 40 Address: Address:5024 LOJW41 A4. #49OW JO City Zip: I te 4 Phone #: (�) '9.5 2 03 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Name: Signature: SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: %/e;OTo7— AddressAW Al. City' :Tu/eLVC041LZip: 9 4r Phone #: 104p) s� fa - '�� %p Date Tank Received: Name: Title: Signature: ######################################################################################################### EH 23 046 (Revised 9/11/96) Page 10/?,