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SAN JSAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> s»sr*rrts»krtis#ttwtr+iwt*kwrrrwtrrwskrirrrwi*sat+*iwi»rw+risrrr+++i*ttrwrt#krt+its+t»rtawiiirtrt+*tri#i+sit»4ii <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: T <br /> FACILITY ADDRESS: 9Z7 &/L9CL� -MnW&AD lr..4 S' LoD/ 04 • 962 1K:2 <br /> TANK ID #39 - I Z TANK SIZE: O o0 PREVIOUS TANK CONTENTS: =L-- <br /> irtrw»t+*rw»t**w»+itirk*sirr**+r+rir+k*tiriir#wwksts•+trt*ir*+i+t*rtt+wi##s»*ri»+irttt*ii+#it+ti+#irir++rrw+# <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 130L,., r �A.r/SfQ t�TGYJ E�✓�� "/OL <br /> Address: 3330 A ,0w/� Gorr. city: 4Zr0cf'70),4'1 Zip: 9520,6 <br /> Phone #: (��) �fOfi'✓��/ Date Tank Removed: <br /> tt»i+rrt»t»t+t*t#tt#*trtr4##twt##aiiir»rtt»kw»rtt*ttittiti*wit+#r»+#*rt#+rr*+4wrirt#rri+*#+#tiwkt»irt+#rti+*»+t» <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: 2wgw ( F/•c'�7JQtlG�fdiJ '�N(r/•���'''U�� <br /> Address: 3 3 Fro *,-,06/� rnpwv— City: tr 7[1G Zip:�zo_ ,6 <br /> Phone #: (Ze4) 5/Dg15-Z/5 <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:/`/ /it/f57W� Title: OW,4E/� Signature: !✓� — Date /d O <br /> ***i*trt»ts*t*trt+k+rwirirtw*aa»iirtrrrttir*rtir44i»iir*itir+itt+strt+r»wi#rwris#tis+iittirrstir+ii++r+krs*irs <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 /> rit+»*t*rsw»rtkwtwt»+ikk**r»rrttr*+rr*wirarrwt*rt*is+wari+»*arrrtrt+a»trtk+rwtrt*ws*»it**trtt#»wtitwi►iit#*wr*r#+ <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />