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SAN JOAQUIN COUNTY PUBLIC HEALTH SEReCES <br /> ENVIRONMENTAL HEALTH DMSION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> Y///#Frt/W/r!/W\#+#Yr*/airt/#rrtli\/aR+rtr*ar»\rrt/!i\/rt►rr\r/\rtrtrrtrtY}#ialarraarrt+rtr#ar\#r//rtr}!ri/rr►r!r}#rt+/+r <br /> SECTION l - 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: ry <br /> !3 ha wy`'� T % <br /> FACILITY ADDRESS: Cl Ito ' 6rom k ay 5focr-fon CIS 4AjrZ�r <br /> TANK ID 839 - l�a rJ O a TANK SIZE: PREVIOUS TANK CONTENTS: IVQtfif n. <br /> *W!///irrltrtY4W//rtr///4rt#}r#+#44rtii#wrrt#/rr4*/r//trtYr#/W//irrrtY/#/+rtr###r/#artrrrt►rr4rtrtr/rrr»rtlirrttrtrr/iirrrt <br /> SECTION 2 - To be filled out by tank removal contractor: A_ <br /> Tank Removal Contractor: P�ydir� �YPQVaf�ltQ w ' Tri - <br /> Address: auq OrC <br /> Cf 1 ��5ttf��n ity: Ripon Zip: aS Coln <br /> Phot;t,( aDq 5�Q -ev 4 / Date Tank Removed: <br /> YWrr#r++rr*/#rtrtrWr/+iairt//W+#W//#►»}+rt+r/►rt4/++r/r+rs+►W/r/rrt#r+##+Yw##a»rr#air/#*rW++rr/}+r*r}►r#r//r++rr+ <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Pa�ldlr�- L.YlrGllflflVIVIT py, — <br /> nn�� ,(a i q5 3(do <br /> Address: o(� n ul' � '.. '/ '� City: Ripon Zip: <br /> hh <br /> Phone p: <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: Tide: Signature: Date <br /> /rtrtrtrrrr►rr/##+rr}rrr#/}*rrr/#rtrtrrr/+/rr/rrtrr}rtrrr//ria►rr//r+/a/#a**/#r/rrr++ar►r}+»rrt/rtrr/•/#rr/rr/rY/+r/ <br /> SECTION 4- To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting <br /> t tank and/or piping. <br /> Facility Name: L r1 pba-�y Mf0. <br /> Address: �l� I6q0r, vWMWD� City: T�LYJDCr Zip: gj53fo <br /> Phone k: ( 6 tL6 0 qF62 <br /> Date Tank Received: <br /> Name Title: Signature: Date <br /> w/rtrrrr/rt/#rt+rtr/r!#rtr/##laarrrt/}r/r\rrt/wlrrt#//rtr//#/r//}rrr/rrrtrrtrr}r##a\r/}/arrr»r!#rrrW##rrr/r/rrr/a+rr <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />