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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACIWG RECORD <br /> f#rrtF<FarIFYYF#«#«##r########ra#r/##r###r###r#rrFftVVY#<iff#rFrrf Fif Yrff#4frfrff#f###ffffr##lfrr«ftrr#air# <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: )e uEt- UtaGAyo,,L9L G'{.�we� <br /> FACIISfY ADDRESS: 9-55M I,tA tst�J 9-& . 'r62Auy c,1 . �+�37 6 <br /> TANK ID N39-TA. OW-.5 TANK SIZE: Z000 PREVIOUS TANK CONTENTS: 0/,Wt 2 <br /> «#•t+tY+/t#iaara####r#rfrrfr##rrrt►w###■YYaf#raraY/f/frrr####rY/rfa4f#aa#ra###rfrf###//#af##ffffff/tffta•#t <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractocjo&�y C�V1(Lo we+JTf}(� <br /> Address:5173"0� G( 2 . city:ezDo- 4�D 14as Zip: <br /> Phone p: ( 116 ) Y3i- 43 Dau Tank Removed: T,a,11 . — <br /> +Fa<#«F+Frr#rtr4rrrrrrkxxFFtrrrF«r4rx«krir+<kxFxrrxx«rwx«xrkkxkxra«k+wr+#rr«rrtrlaFx4lt##rr4##<#t#ff4rlrff# <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: /yfirwS T/fL <br /> Address: S-1 �— S. Q/t&;VL112�, City: W e Zip: <br /> Phone M: ( 7/6 ) 37/- IT Z <br /> Authorized represemative of contractor certifying through signature below that the tank has been decontaminated in as approved <br /> manner as required by Cal EPA. 'rte 0 r .� " &D Co. jo A u th'w1 Do-v-- <br /> Name: <br /> o.tName: Tide: Signature: Date <br /> .r.rxww+Fakwwww F<ww#rvwY«rrwawlwwwl44wrlr4i4w!lrr44rwr♦wrw<wwwlrwYrwwrYlwrlrrwt4Yr♦#w«#art4e«aakrlww#«Ftkk <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 /> Facility Name: 7'l/fi✓b&c <br /> Address: 3Sd5 (/145�)Naal A#C _ City:IryutAmcpTO Zip: 7S—V3 <br /> Phone K: <br /> Date Tank Received: T 1?-A . <br /> Name: Title: Signature:_ Date <br /> +.arwxxr+r+t««+++«w+xx«+#x«r+xrrra+r««r+•rrr+rxxxxrrr••xrxxrYr«rerrra«r.«xrxra!<xrrrrar•rrwwwwrrrrxr4tYrr <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />