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BUSINESS OFFICES Fax : 209-9432811 Jan 28 06:38 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> WWWWrsWlYYrrWWi#RkMnW+iiiiMWrrNYYYWiiM#kMriiliW#RMWYYYYiww!lMrMlrYYYYW##MlrYWYWMWYlr#rWrrrrrWlMrrYYrwrlRrr <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 clava of acceptance of the tank by the disposal or recycling facility. The permit holder,is responsible for anauriag that <br /> this form is completed and returned. <br /> FACILITYNAME: LIBERTY FIRE DISTRICT <br /> FACILITYADDRESS: 24124 N. BRUELLA R AO . ACAMFO . CA 95220 <br /> TANK ID#39 - TANKSIZE: 550 GAL PREVIOUS TANK CONTENTS: IINi t=nhFn r_aSni TP E <br /> !!lMWwrW W+++#Y+lWMMMrMWWwYii•MMrMMWWWYWYwiW+W#Ri4rWYrYrrwwlirYRR•RMMWWWNrwwii#i►kkkrMMrYrrrrWYWrwWwwrkMrMlk <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: JAMES J . HOBLITZELL <br /> Address: BOX 30331 City:STOCKTON Zip:95213 <br /> Phone p: 2( 0 9 ) 943 7793 Date Tank Removed: <br /> Mil,MrMYWWWrYYtrirrrrs++MMMkMrrrYrrYWWWr1Yi#rR#lkM1.MWMWrrkYWWWYWWii##RMTiw!#k#MirrrrOWWrrrrr►YWWWWrWWWW W♦iriY <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: JAMES J . HOBLITZELL <br /> Address: BOX 30331 City: STOCKTON Zip: 95213 <br /> Phone#: (209 ) 943 7793 S <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in in approved <br /> mamer as required by Cal EPA. <br /> Name: Title: Signature:_ -- _--Date <br /> •.+...#++#!rl+r#RWMM+.WwrMwwrrrwrwrY.•wlrrr•rwrwM•wwWrrYlrrgrMMrrWrrYrrrrrrrrrryrrwrrrrrrwrrrYwwryYWWWwYY <br /> SECTION 4•To be signed and dated by an author(zad representative of the treatment, storage,or disposal facility <br /> accepting tank and/or.piping. <br /> Facility Name:WE5J COAST EQUIPMENT <br /> Address: 1221 TEGNER ROAD City: TURLOCK __Zlp: __95381 <br /> Phone#: 2{ 09 ) 668 9378 <br /> Date Tank Received: <br /> Name: Title: Silinature: Date <br /> R.rwrek!#.trr..R#fR#..rrrrrWrrrrwrrrWWrrwrrrr•rrrwwrr.rrwrrrwwrwrY•WrY.••Wrrrfwrr+wrrrrpwrrrrrrprrrrrr <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />