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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENvMONMENTAL HEALTH DMSION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> }I - Public Health Services Environmental Health Division Tank Tracking <br /> SECTION king 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: st Mwy)t <br /> T <br /> FACILITY ADDRESS: aS ) PM r W-� <br /> T.NK ID ,f39 - 1337-3 TANK SIZE: L3 U-60 PREVIOUS TANK CONTENTS: 6A<,t�l <br /> .#.w..##w#}##}.#wrt#}#iY}##}i#w#}}iY}}i#}i#}}ii#ii#}#}}###......#}}ii}#i..............#}##w###i}#w##ww...... <br /> SECTION 2 - To be filled out by <br /> tankremoval contractor: <br /> Tank Removal LContr`ac1tor. ` —/� <br /> address: 1 W C�`I C�-�V G City: O,CC(�DGI� Zip: �D <br /> Phone ( ) ► g'15Date Tank Removed: fO I <br /> ........................#...............}.w}..................#..#....Y#..Y#..i}}w......................... <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": p <br /> Tank Decont_att/unation Contractor:gDZLZ T-C�- &'� <br /> address: I VD���1(� �.l0L aQt}� City: � Zip: <br /> Phone ..# (Ar T� S <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> mane: required by Cal EPA. , <br /> Title LrA,— Signature Dace <br /> Name: <br /> #.......} ...............................i#rtw}.#...i.##iY}#####Y.# }i#}i#.Y#i#rt.#}.........w..} <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting muk and/or piping. cam- 1 rn t r <br /> Facility Name: Q <br /> Address: t l `� TAll L�- 15I t I kx)-o1R City: T� �..tSZ�. Zip: 157a I <br /> Phone .;: <br /> Dace Tank Received::/ 0 I 1r b <br /> ?fame: <br /> �7 I�) h� Tide—1 r �-c1 ���v�� Signature: Date <br /> I lr ^� ✓� � � <br /> ......................}....................#rtw#.##rti.}}.......w..irt.......i............................... <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />