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SAN JOAQUIIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND,STORAGE TANK DISPOSITION TRACKING RECORD <br /> !iY#H!•P##lwww•#w w..•.•♦wwYrWYYw•www N......wb♦lWw WWN rwiw......wrw Yr YYANaY W►Yrwiw rswww YYwYYYWW W►►Wr►ir <br /> ECTIQN 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> s site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> jl�yln30 dare of accep=ce of the tank by the disposal or recycling facility. The permit holder ts'•rsspoasible for ensuring that <br /> ,is form is completed and returned. <br /> 'ACILITYNAME: LIBERTY FIRE DISTRICT <br /> ACILITYADDRESS: 24124 N BRUELLA ROAD ACAMPO CA 95220 <br /> ANK ID k39 - TANK SIZE: e GALPREVIOUS TANK CONTENTS: DIESEL FUEL <br /> ##•#wwarw#lPHNla#Wr.wrrwrlw♦www#IWWarYYrwrUw#Warr►WYfii rrw♦HlaYWWYrrrw►•r!q#rW WWY►w►rwwllrrwYWYw•##♦ <br /> ;ECTION 2-To be Riled out by tank removal contractor: <br /> 'ank Removal Contractor: JAMES J . HOBLITZELL <br /> �ddrcss: <br /> BOX 30331 Ciy:STOCKTON Zip:95213 <br /> 'hone #: ( 219 ) 943 7793 Date Tank Removed: <br /> !!#•rqw.Ywr!#YYr•rwrur•#wwYY#YYWaawrwwwrrwwrrWaV•rww#rWrrrYWrrr#••grrw#YwwrWdrrirWawr�wwrY►Ww►usYW► <br /> iECTION 3 - To be filled out by contractor"decontaminating tank": <br /> rank'Decontamination Contractor: JAMES J . HOBLITZELL <br /> kddress: BOX 30331 City: STOCKTON Zip: 95213 <br /> ?hone p: (_2 0 9 943 7793 <br /> kutborixed representative of contractor certifying through signature below that the tank bas been dccootaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date_ <br /> ##iww•wiir#rslr•WYWW►wi.aM•W#.!Y►yW►YYWYYwYrwwrrWWrW►ww►♦rarY►WYW►w#!♦rrY►WYr►Ywwwwwiy►Y►►YwWY►►WwYr►wwWaa►• <br /> SECTION 4. To be signed and dated by an authorized representative of the treatment, storage;or disposal facility <br /> accepting tank and/or piing. <br /> esf Cons'` fcu�;-,r�„�/ _ <br /> FacUiry Name: <br /> Address: city:�uo- 4-C Gey Zip: <br /> Phone X: ( ` 379 _ <br /> Date Tank Received: <br /> Name: . Title: Signature: _ Dates— <br /> Nw#M#♦♦awr►rwwwrWWrwra#r#•w4►rww•rrNWYYYwwwwwrYYYWY#wwWa►WWY►rwwswwWWgrwwwYYwsrYwhYraq►wwMYYa•wwwraY <br /> Skt 24 4t5 {Revised 10/19198) Page 10 <br />