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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 returned 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 is completed and returned. <br />FACILITY NAME: 14^0. -ear <br />�L�®7 <br />FACILITY ADDREESS: J 4? /�+ w`9— �,ewT A <br />TANK ID #39 - �J d2 TANK SIZE: S 5 d PREVIOUS TANK CONTENTS: 4CGA��� <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal <br />Contractor: '6,C� ��Y'ST�p���r��� 4'0' <br />Address:-902.6-R.41y46,4me -0 2J3_ City:SnA Zip: 4957z/ey <br />Phone q: (!4 ) fr14—+ Z4+ — Date Tank Removed: <br />########################################################################################################### <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor:_�e �W ����` �if*�6 <br />Address: wep zo." 41104= &-�e ae City �'' �r�Zip: 41�40 <br />Phone U: (� -4!:p <br />Authorized <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />maturer as required by Cal EPA. <br />Name: <br />Signature: <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: &57e2 S,77 <br />AddressAW M. WOW/ `f ® <br />City: %� .Aw CAL Zip: ns - &&V <br />7tr <br />Phone M4419) b <br />9.3 <br />Date Tank <br />Name: Tide: Signature: Date <br />*#*###*###*#####**#*#*##*##################*##### <br />EH 23 046 (Revised 9/11/96) Page 10/G) <br />#########W#### <br />