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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> w......xxsrrtxxarxrtxxwsrxrxxxxrrrxxsssxsrrtxsrrxasrxxxsrrxxxxxxxxwrrtrrxxrxssxxxxxxxxxssssxxxsrsrtxxxssrrtrtrtrxxrt <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. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: �6 o\"5 IVB 1 C� RTI�J l <br /> TAINK ID 439 - TANK SIZE: Q iSeS'� PREVIOUS TANK CONTENTS: SLI. <br /> .www.............I....sr...xr..>rr.....rr..x.tart...rrr..r.x...rxx...rtrt...........*..s..................... <br /> SECTION 2 - To be filled out <br /> by tank removal contractor: <br /> Tank Removal Contractor: kiT ffc,�� (Tepk `���—/n�� ^mA ?RyR) 1 <br /> Address:��IO� � ��V� City: IJt�C�/4 Zip: 95361 <br /> Phone 1: ( ),P1 ) 94-1 (34) 72 Date Tank Removed:_ <br /> .rt........rt..........x.w....rt.........rtr..x.rtr.....xxxrr.x..rw..srr...y....rt....r............s............. <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": p p, <br /> Tank Decontamination Contractor: p2y . T-C't'll' Tezj,�-A v4r� 6-" wp�t <br /> Address: OL106 >El-1 City: dlh � Zip: 1 �3� <br /> Phone ,f (A) �1 M2 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner required by Cal EPA. q <br /> Name: t Title: rlx ' Signature: Date 1 I b <br /> ..w.rt..wr.. r....rrr..rt.rtrrrtxx.art..rt...rrt.xx.rtr.x...r...rrt.......... x......................rt.x.. <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. VIOL <br /> Facility Name: �c�glC // Q <br /> Address: ��A t 1. 1 ` - ToklL6 / 5�L1fQ. City: T4 Zip: I�J7� I <br /> Phone x: ( D-59 ) 6 6& 33 9 <br /> q-2- <br /> Dace Tank Received: <br /> Mame: R r4 r y f lz Title: k UK 01-i v�- Signature: <br /> .........................art...................r............rt.art..r...rt...rt.................rtrt..rt.rt..w.... <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />