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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> raw>irrr..>swrr+frr.Mr>srYrr«rrrrw>Y.rarwraywrrr.r.Yrr.rear...........***.......rrnrr4...brrraw......... <br /> SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheer shall accompany each tank affixed wits <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: k RAI <br /> FACILITY ADDRESS: <br /> TANK 1D k39 _TANK SIZE:,.� PREVIOUS TANK CONTENTS: rjy 4 <br /> rr«r!«►...>rY►ww>..4.rwwr...rr..rY...Yrrr>Yr««wr««a!Y«..>r...>w>irrrwr............. .—*...... ......i...... <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank RemovalConrractor: <br /> Address:�� t c t7�� q90 Lr,1 Ciry: �, 2ip: � <br /> Phone:: (.-1O0) 9 �'DlaDto Date Tank Removed: <br /> rr rw...r...r..rr.ar...+rsrrrrsaarr..rr.r.wrrr..rr..+a>..............w.rr.....s...... <br /> .�..• <br /> SECTION 3 -To be filled out by contractor "decontaminatittg tank": <br /> Tank DecOnLlmLltaL10R COntI tOr:��� <br /> �O� V union r- <br /> Address- City: 57aCK%a�l Zip: � <br /> Phone;:ip <br /> Authorized representative of contractor certifying through signature below that the t b e decontaminated in an roves <br /> maturer as required by Cal EPA. r' r` '' l <br /> GtAAT Si!?taturel ' `G-r- s <br /> Name: 1}�� •]r'�S / Tule D w -rfu L <br /> .iw.lrw.«>rrr.rr....wwr>r>.lw.rfYraY.rrrr«.rYr.flrO>Nl....>yrrr>w.wrain.w.«.wwirrarl«l.rwrrr..«l+ir.:+..� <br /> SECTION 4•To be signed and dated by an authorized representative of the treatment• storage, or disposal facility <br /> acceptmg rank and/or piping. <br /> Facility Name: ll Tu 5 _ _ <br /> c7 r � <br /> Address. I City:/ 9�-eF.SrL zip: � - -- <br /> Phone P (Ina-) <7 37 -`f 769 6, .t `- <br /> Date Tank Received: g��0 ��`V `� <br /> Date <br /> Name: Tide:_ J SigoaSignature: <br /> r.��«r..rrrr............«................•.*...rr............. <br /> EH 23 046 (Revised 08/13/99) Page 10 <br /> IOO d i8L8 f89 OIS '13L NI NOl,L9f18,LSN00 88 80 9i (3(1,L100 ,6t O(ltl <br />