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I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - 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 rhis form is completed and resumed. <br /> FACILITY NAME: <;TAI, 1\'' lol I (� <br /> FACILITY ADDRESS: <br /> TANK ID #39 - 133-7-Z TANK SIZE: Q t� _PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out byy-tank removal contractor: <br /> Tank Removal Contractor: bE' T Ez�)A" <br /> g4-1 <br /> ( � <br /> Address: I� OL\Vs �� ` City: O/- i�P Z�ip: <br /> Phone #: ( M ) rnI-1 <br /> 3n� Dare Tank Removed: <br /> ............ <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decont_amrinatiilon Contractor: w��T`�1- <br /> Address: VD,--T n�-IOiE >B(}� Ci � Zip: 1 �3� <br /> Phone ,t: (An_) C4, s s!] <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner V required by Cal EPA. q <br /> Name: t Title: 61kft1LA— Signature: Date 1 Ib <br /> ...#}.... }...........w............... <br /> SECTION 4 - To be signed and dazed by an authorized reprsentative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. ^ t , <br /> Facility Name: <br /> \ - (' ( <br /> address: a )� )I t p 1 l �f�� �R / 5 L�fQ city: TLj-&L UZ*-, Q Zip: 53 <br /> Phone #: ( ) 6 6B `�3 gZ <br /> Date Tank Received: 112 //Z <br /> Name: t _Title:_ynn ,c -LSignamre: �jZy� ate <br /> ..www..}w.#.}}..w......-.#rt..w}w#wwww...w...w...w..........................• <br /> EH 23 046 (Revised 7/10/96) :'age 10 <br />