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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HE.�-LTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD 1 <br /> ........................................ .......#.......r.r»...}..>.}.}#..}.}}}}}r>}}>}.........�.}...,s.>. <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 resumed to Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the disposal or -ecycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: S-y A>>t M,,`` I k'E ,r <br /> FAC?CITY ADDRESS: <br /> �5 o�5 lAgR kN b T <br /> TANK ID .i39 - 3i l`Z TANK SIZE: <) J P.,EVIOUS TANK CONTENTS: tel <br /> ............>......»}.#»...}.}}}.}.}}#..}}}..>#.}.#}##,..}.}}..}}..}}}..>....}.........>}.......>}...}.}» <br /> SECTION 2 - To be filled out <br /> byyttaak removal contractor: <br /> Tanis Removal tContr\\acor. /n.��,a,^,�P�� <br /> Address:��C `I ��V G �' -- City: �rvlw4 Zip: <br /> Phone r: ( ) 34-121 T2D Date Tank Remo,ed: � I <br /> ...................................}..}.........................>.......................................... <br /> SECTION 3 - To be filled out by contractor "decontaminating ta:.k": p p <br /> Tank Decontamination Contractor. ram—T —►�4 CSS ` ' ��� rQ�1 <br /> Address: 0, <br /> � yD� TT, LIDIE r9(}� City: ��"� Zip: <br /> IS <br /> Phone : ( ) -1 M 2 <br /> Authorized representative of contractor certifying through signature l Blow that the tank has been decontaminated in an approved <br /> marine: required by Cal EPA. CIAq LL <br /> rSignature: Date ! I D <br /> Name: Title: <br /> }}.}..#..#...>...#...}}.}}}}>}.}}#...>.>..}.}........... .....}.............}>....z.. <br /> SECTION�4 - To be signed and dated by an authorized represent::sive of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Naarle' M c: Q <br /> Address: { W I t 1 1 `d- TA41��{Z��LA&- City: T��'� IBJ Zip: 7Pi I <br /> Phone ": (�� I <br /> ) O 68 `M-2- <br /> Date Tank Received: I i .ri' I b-){ - <br /> Gj t ) /: Title / r w� �n'v SiSai: <br /> Varve: r :.fin <br /> ......................................................................................................... <br /> EH '_3 046 (Revised 7/10/96) Page !) <br />