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SPAWNEIr I <br /> IMF <br /> SAN JOAQM COUNTY PUBLIC HEALTH SERVICES' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Pr 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 Envirorunental 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: j 1 F:r— l y <br /> "4&! — <br /> FACILITY ADDRESS: t Z-01 4�, rMmg4r- � <br /> TANK ID #39 - TANK SIZE: 10 00 PREVIOUS TANK CONTENTS: <br /> SECTION 2 -To be filled out by <br /> tank removal contractor: <br /> Tank Removal Contractor: <br /> ��Vr I--S� �N G1 Nrc(��►�G <br /> Address: �L fri/1V, S 11)6 1 04V City: fZre4)0lWj Zip: <br /> Phone #: (.S� ) �' Date Tank Removed: U&y PJYFW ItL Olz GoJ"16( <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination/Contractor: Vt� 61N���IKf4 pper''' <br /> Address: 39'9'3 / Sl L16 � City: &:0 D l/46r Zip: 9(000 <br /> Phone #: - A'i•s363 <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: 1�+W 1� ��� Title: O±g fog- — Signature: Date 6 ®� <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 /> Address: City: Zip: <br /> Phone#: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 08/13/99) " Page 10 <br />