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.. ../ r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD y.......xxxxx.xxirxxxii#i#ixiiixxxriiiixiiiiiiixiarixiiixiixi.iiixixixixxiirixixxixxi......rxxixrxxr SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for easuring that this form is completed and returned. FACILITY NAME: S I r.*ft YY1k�E FACILITY ADDRESS: : rs 0X5 �I�( TANK ID #39 - 1i31' I TANK SIZE: Q � PRE'/IOUS TANK CONTENTS: .........xx....x......#i..xx... .... xx.x.x##xxxx....ri.#xixx.x..#.xx.........rrir..ssx.i.a.rL.....>. SECTION 2 - To be filled out by Link removal contractor: Tanis Removal Contractor. bL L T E�A '/� Address: 1 D� 0V�ry City: ONl �q Zip: Phone )-34-1 Sr) rJ 1 Date Tank Removed:_�� J I ..................x......x..x......#........i.x..x.xi............x.........x...............................aa SECTION 3 - To be filled out by contractor "decontaminating tank": p p. Tank Decontamination Contractor. DiELT�-4- CSS i 5AA-n rq�1 Address: y0� 1 0 City: 6-FAZ,1> Zip: Phone ,: (An p 5� Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved mane; required by Cal EPA. q t Gv � Signature: Date Same: Tide: 1 I b >.x.....r ..........xi..#iiirii.iii#i..iii........xi.#.i..xii.xi.. xixir.i.xxxxi............... SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. �CAL ��r,,c y Facility Name: t�U � q ` Address: ��'{ Ci `j `d T�1L� / Isb I Ib`l - City: T�-� Zip: 53 l Phone ,;