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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. 1 <br /> FACILITYNAME: (at,� ,�eLnr'i� 7T <br /> (A' > V—Vv�PZCZ <br /> FACILITY ADDRESS: k \'zm�)y S, �U <br /> TANK ID d39 - Sq TANK SIZE: ((; r)n PREVIOUS TANK CONTENTS: l�i(=Ca <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:SAC\nOA Zt �� fjiSe�kVIAC/tkA«lAL-CtC-AA ,I <br /> Address: a n 11�X ( City: jN�A\-At >,tr In Zip: EkL <br /> Phone q: (-S3( )-7 — Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: L T !Qtz l AV N rcjCDtA2j[U <br /> Address: I(.,Ck __ City: Zip: <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 Cal EPA. <br /> Name: Title: Signature: Date <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 /> FacilityName: <br /> Address: �S(� Z�� t t(? City: ,I<a�r. o to : C, <br /> Phone H: A I(,, M(An <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />