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SAN 16AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> *wt*w*wrr»rri++++*wrtt*rtittwrr*rtt*+twt+*twrt+w#i*s#tt*trot***#+*#rirt*+rtiwttrtrttrtww*trt+w*#++++#+*++*+»»+i»*r <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: 224; > 41,QArv <br /> -- FACILITY ADDRESS: ?27 &efC4 4J91,�d[i0 Gr.44 J,� j, 4eA01 ,, 04 • 962 fA0 <br /> TANK ID#39 -#/yam.#STANK SIZE: O 00 PREVIOUS TANK CONTENTS: V/"eL� <br /> ***w*+*+*#+***#++*rww+*+r+»irrtwrtrrrrtt*t#**t##»»#tt*t*t+++#irtttt**tw**+i»ti*rtt**w»irrttt##++wrrttr+*+i+rrtw++irt <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: g0L./F-ilk ��a/ST��Tf� Ei✓yy'� /^�� <br /> Address: 3330 A::�O.ri/G GOf/R-f- City:�TdCCTTJN Zip: 95 00 <br /> Phone q: ( ) yOfi-✓�Z/ ;- Date Tank Removed: <br /> ##+#+#t#+trtrtirttrt*##***»+#w++t*rttt#**##++itrtit#++#+#rt#i*#+k+k*r*#+»krtrti#++#rrtw+*r****irrtt#*+irtitttitr#tit+i <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor.' 'G! C oNSfJ�1l[i �.J ' EiU /�✓L +�/tiG <br /> Address: 3330 �Oti// COvh1— City: 7VC0•CCTLW Zip: y ZZo <br /> Phone N: <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by <br /> Cal EPA. <br /> Name:/`/�QG/,{/f�7/w/�t� Title: Dw�VE/1i Signature: /✓7 Date /d O <br /> _ **+t#++*wrtt*wt+w++#wtrttr*t*t*+#+rt»rtrwt*#++rwtwr*+»rtrt**t++rtrrt+kt+rtrtww+*****4rttr**+rtrt##+rtt*+++war+rt++»t*+r* <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: Ciry: Zip: <br /> Phone N: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> _ **++i»+twit*+»ri*iwrtw*++i»»rrtrtrirt*w#k+rtiw+»»it**+rrrt*#»tiwt**+»irrt**+rtr*+trtt*#ar#+»i**+rttw+#r*#+ir*»»ir <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />