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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: SJ-X\ <br /> FACILITY ADDRESS: dS X5 1 ►�"`l� <br /> TANK ID #39 - TANK SIZE: O LTJ PREVIOUS TANK CONTENTS: 1 <br /> SECTION 2 - To be filled out <br /> bytankremoval contractor: <br /> Tank Removal Contractor: Tp��P � 6 <br /> Address: I�� �`-�V J - City:_ �N� Zip: �6 <br /> Phone 941 gr)T29 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: yD�--l' 0,�-�t) t9(j Ciry: 6—PAZ *G� Zip: <br /> Phone , (�An _) C4 S <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner required by Cal EPA. , <br /> Title:' Signature: Date <br /> Name: <br /> *##}}#}**#*}##}# ##+*}+###*}#*}}#*+}*##*###}}##}+}}}##*###}}#+*#}###*}### #}##}}}#}#}+}###}*##}*}##}#} <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 /> CCIC4�T C� 1 <6 <br /> Facility Name: a dSgKd tvY,-� W' Q <br /> Address: � � 111 `� Tf l 6� 15 t� ( ML99, City: T�� Zip: <br /> Phone #: ( ) 'O 6& '�S 9 <br /> Date Tank Received: <br /> Name: Tide: Signature: <br /> Date <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />