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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> **#**#***##*****#*##**#***#*##*#*##*##*#*##*#*******#*****#*#*#*#*#*#*#***#*###*####*#**#*#*#*##**#* I <br /> SECTION I - 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 I <br /> this form is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> ' u t <br /> 7/? <br /> TENTS: <br /> TANK ID#39 - �� <br /> TANK SIZE: � PREVIOUS TANK CON <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> rR Fn <br /> Tank Removal Contractor: v <br /> rs�-- <br /> _ n o e1_ Zip:0 Ciry: <br /> Address: <br /> Phone#: <br /> 4 Z .� n (� Date Tank Removed: <br /> (�9 >�� <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> City: S <br /> Address: <br /> �-,�...._Q rd_ C,Cr°�✓ zip: <br /> Phone#:&?d S ) �7 '3 2 - Ot`4FrV <br /> through signature below that the tank has been decontaminated in an approved <br /> Authorized representative of contractor certifying g gn <br /> manner as required by Cal EPA. <br /> Title: Signature: <br /> Date�� <br /> Name: <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: <br /> City:—Zip: <br /> Address: <br /> Phone#: ( ) <br /> Date Tank Received: <br /> Title: Signature: <br /> Date <br /> Name: <br /> EH 23 046 (Revised 08/13/99) Page 10 <br />