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C `W \/ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> .......a.#rwaarrfa+»rfrrf#####♦aarrrrrr►r144rra44ra4l1►arr►r4al►►►!!►l4►a4ilala4a!!44la44444#4alaaa+a+aa.aa <br /> SUCTION 1 - Public Health Services Environmental Health Division tank tracking Sheet shall accompany each tank affixed <br /> ,ci,h its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> I iivition within 30 dam of acceptance of the tank by the disposal or recycling facility. The petttllt holder is responsible for <br /> �nm,ine that this form is completed and returned. II <br /> I'•\t'II.ITY NAME: <br /> VV 11 ITY ADDRESS: <br /> q <br /> 1 n^tY. ID #39 - 1$�( - I TANK SIZE: ��jnn PREVIOUS TANK CONT11NTS: NI -t✓* <br /> ........«.aw.«r.rrr•!af##a»aaararr4ara4rar!!4»afa#araa44#+4r4l4rr►♦4a4aa+a44a4r»arras#arlala+arwf:a+#a«wan. <br /> W(-T'ION 2 - To be filled out by tank removal contractor. I <br /> t.nb Pemoval Contractor:S `� n F] �l2'nf'i \Czlalti ('�r`)\/�Sl �(`l).C.`C�O� <br /> City: /QAAc �n Zip: 9C(n..C�l — <br /> ftnm, U ( 90) 'B4w-9- - Date Tank Removed: <br /> .......aawawr♦«aHwa4w♦fMM#alrrrMrraaM#rfHrraaa44garf4#a4+Ria»4a4a1»a444a■►4aaaa»+ran►•Mlww4rlwaa+aa <br /> �I'r'1'IrIN 3 - To be filled out by contractor "decontaminating tank": <br /> fait: Decontamination ContractorA_n�^kAAf tai O(2 jVj-AieA Maw <br /> �,bt,Pce: ��1 amu-�•u� City; lal wyln Zip: C <br /> Anthori7ed representative of contractor Mrtl6log through signature below that the tank has been decontaminated ht an approved <br /> „inner as required by Cal EPA. <br /> a,nef Title: Signature: Date <br /> .•....ar:»:sa#+44»♦ar#arrrrrailaNMFr►rr►a4NNaa►l►allalalaa4ai�a►raaia►liiiiaaalaara444►a4►►a►a4a#»afa#:+ <br /> S CTTON 4 - To be signed and dated by an ertthorized teprese tmidre of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> fm:ility Name: f t(P- <br /> City: ! Lj6 zip: a ?3 <br /> i <br /> Darr Tank Received: <br /> vane: Title: Signature —Date— <br /> .......... <br /> ate.......... <br /> IIt " 046 (Revised 9/11/96) Page 10 <br />