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SAN JHAQUIN COUNTY PUBLIC HEALTH SER"CES <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 with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: TbaTj -t ii6/y{L /!7 G L!A&1l ✓ <br />FACILITY ADDRESS: SIS tsc t� / �A � <br />9 s�j <br />TANK ID #39 - -5_7q-L) TANK SIZE: (/000 PREVIOUS TANK CONTENTS: rnfg <br />--- 7 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: >6i," Ca <br />Address: f Z- I ��� ��. City: /til oO6570 Zip: l Sat <br />Phone #: (�) S� . %� J 3 Date Tank Removed: %D� /75' <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: ru_� C -O <br />Address: / L ( + S • q � i City: M0dt�- t0 Zip: <br />Phone #: (7,0`f ) S�•y — 9LS-3 <br />9 a3S/ <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: <br />Title: <br />Signature: <br />Date <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 <br />Mo1/� Jlcn� <br />Address: I S �3 / City: MO)it7D Zip: /S✓S T <br />Phone #: ( Z0 ) <br />Date Tank <br />SZZ -IY3 S_ <br />Name: Title: Signature: Date <br />EH 23 046 (Revised 10/19/98) Page 10 <br />