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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DrirmON <br /> UNDERGROUND STORAGE TANK DISPOSmON TRACKING RECORD <br /> ra/w+rw«rwwwwwsi+rrk/rk4rr444Yww44w+rr4wrrrr.rrwwrrrrrrwwrrr..si.+ia.row/«4iiirrirri/rpit/iY/4RRa+rr.«•ps <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identification numW. The Tank Tracking Shea is to be retuned 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 retuned. <br /> FACILITY NAME: UAL UorRj-t otj PL <br /> FACILITY ADDRESS: 9bgD0 VCS SZ O . Z'( /A" C-4 . 9 J 37(o _ <br /> TANK ID#39-TA IIo3" TANK SIZE: ao00 PREVIOUS TANK CONTENTS: A& OA/Lcio(Jti ) <br /> +iarari+kr4kY/YkrYY/4YY/YYri444Y44rRr444kr41Y44441r/Y/YYr4/414Y4w/Yw44Y4i4i/YiirrYi4iiirri►r4lr4r/rkk#4Y{kk <br /> SECTION 2 - To be filled out bby,tank removal contractor: <br /> ou <br /> Tank Removal Contractor: �J �_"j L-10JVt9-0.)WAa� • NL <br /> Addtrss SI_)J-3 0-4LLSOALC- Gt2. Ciry:(-3- 0UQApp H,Lt$zip: 274,a <br /> Phone#: ( q(9 ) q31— 135Y____----- .. -- Date Tank Removed: <br /> R4Rk4444«444i#k###i{{i#r4{{4.4R{i{..{i{{{LiirflYM1i{{r!4{riYiri{iia.itor{#Yia.ekr44i{44rrr44ri4ri.ii{4{4wr4w{ <br /> SECTION 3 - To be filled out by contractor "decontaminating tank <br /> Tank Decontamination Contractor: fi4r4*5 0PV1/(X6PJ0,t,),IgL <br /> Address: City: LJ•SQL Zip. 5,T6911 <br /> Phone N: <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in as approved <br /> manner as required by Cad EPA. N J�e 4V"pf e4T+p Ftp. <br /> Name: Title: Signanrre: Date <br /> •iwa•aii++ir+44r4«!r4«Y4rk4wYrri{{4.i4«#.i4«4{+4444{#4RRr4.x444.Ri♦4.wr.l+i+4r//4rrir#r4/4+Mr+R{{{+a4M#ki#4 <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment. storage, or disposal facility <br /> acceptingtankaad/or piping. <br /> FacilityName: 1711,*J61 e IA16 <br /> Address: �Sr�S SAND AJI'.. City: ���GR9+�1S� Zip: 5� 3 <br /> Phone N: ( yd l- l X10 <br /> Date Tank Received: T a.A. <br /> Name: Title: Signature:_ Date <br /> viiii4ir#k#k#k#{###ri{{4r!{{{l Vrtr44nili{4Rii4+i4#Rini+i{{#.!+#i1{Yaiik#{h#4#lrrk4#R4{l4ri#i{{{{4#iri444#4 <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />