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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TAMC DISPOSITION TRACKING RECORD <br /> «!#iisltiitti«>t}!#i«i###tisii#iisliiiiiiltii4slxxYt-�«iitsii!}ltss4t#slltisltsslttisis#««iiia##airs!!!!}}i# <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 dispo:,al or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: S� 11/,,�11 `,�,�TbMr <br /> FACILITY ADDRESS: . S \LLJ IVt -5 2h <br /> TANK ID X39 • I33t - TANK SIZE: QU750 _PREVIOUS TANK CONTENTS: W&61 Nyll� <br /> .>}Ya>#ii#Y>«Y#«r#Y«irlii###irliiiittiiitiiilt«#Yxix}##tri#iii*tinti#irrii«ratiilti«}#a##!Yr«ii«}}ii>}#aYa <br /> SECTION 2 - To be filled out <br /> by <br /> yy—ttank removal contractor: p <br /> Tank Removal Contractor: bop,� T U� <br /> Address: I���� ��-�V �' - City: ty Zip: �jD I <br /> Phone R: (�M ny)�J' � Date Tack Removed: I �7 1 151 <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: b�T -�v Tk�UA-n <br /> Address: I-D6;Ll' , `OL101E kjt city: Zip: <br /> Phone #: (An_) <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: r Title: 6lkWUA� Signature: DateIM <br /> 1 1� <br /> «aYY>#r»}t>sY#Y ii!#iyi##tittir}ttii}##rrt«!#»#.x«i}tr!!ii}+tilt«ritiit# #i}##ilii>}yi«r#Yi#«i..a..a# <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 /> Facility Name: <br /> ,\ r —a4. � ( C.are{�T <br /> a ` <br /> Address: Awl t q I `� -TArti Lcy—/ 15 t bb I �LoR- Ciry: TLI•� Q� Zip: I5 � l <br /> Phone #: ( >3CA ) 6g �3 gZ <br /> Date Tank Received: �/) Z& <br /> T e <br /> Name: Title: gln,� t}On r( r Signature: <br /> >#.......#.......«#«#}i«>}«#».Y>«}«tx»}x.##>«##>}#xi####>#>xr#=.. <br /> EH 23 046 (Revised 7/10/96) 'age 10 <br />