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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONN ENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> >rsr.s.srsrsr>r.r«rr.wrt«rrtsw*rrsr*rtw*sw*.rtrrtr.r**rs.*r*wrt*rrwrrrrrtr.rw*w*s***.w*rrtr.r.r.r*..srs>w.rw*.>«.r <br /> SECTION 1 - Public Health Services Environmental Health Di- ision Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sheet is :o be retumed to Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the dispo:at or recycling facility. The permit holder is responsible for <br /> ensuring that this form is co-m{pleted and returned. <br /> FACILITY NAME: A::P�, mY�``,,`,,,,ff <br /> FACILITY ADDRESS: ,15 xr) IQ`� N <br /> TANK ID #39 - 133-7- 3 TANK SIZE: O 10 60 —PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: { <br /> Address: <br /> Db a"} ��v City: Zip: D <br /> t—{ r <br /> Phone #: () rn <br /> ) b's I O 5�_ Date Tank :removed: to <br /> SECTION 3 - To be filled out by contractor "decontaminate 19 tank": <br /> Tank Decontamination Contractor: ( LT `-1a— -t5:>T Lr'ZJ <br /> Address: <br /> � 01106 City:_ 6AV-04-(- Zip: <br /> Phone #: ( —) Z4, zm <br /> AuLhonzed representative of contractor terrifying through sip:.ture below that the tank has been decontaminated in an approved <br /> manner required by Cal EPA. , <br /> Tide: Signature: Dale <br /> ;b <br /> Name: <br /> r.rr«r«*.r*sr*>* >rrr««r.r*.#rtrtr«rt*srrt.sr.wr«.r>.>w**r*sr*rw««w*rrrs*r... ............rr.sr*>*>r«>.>ar <br /> SECTION 4 - To be signed and dated by an authorized reprsentative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: q <br /> Address: I 1 A1 "� T LC� / 6�b I Lop Ciry: TI��', Zip: IBJ W <br /> Phone #: ( ) 6 6% rA3 SZ <br /> Date Tank Received: �` �� � 112-����// /per rete;y fo <br /> ��// i �— t Signature: ate <br /> Mame: Tide <br /> ......... R:s � .�P.eG�s� ._..r.**...r««r.*........r.................*............ <br /> EH 23 046 (Revised 7/10/96) 'age 10 <br />