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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> 4ir4a./i4s4iss4fflit4i4f4444+144444rt44444k{44V44s/Vf4t{i4444ffrVOMtrtii/sfiY4f,F441444tfMtOtt4.k;t4s144444fr41s <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 yaL Uf A l I Dn)fl(, <br /> FACILITY ADDRESS; 27 60D VA%DtJ ?-D, C4. 553?(p <br /> TANK ID b39 TA Ib31oos TANK SIZE: 350 PREVIOUS TANK CONTENTS: 40- bju3� <br /> +i.f+aa+r{ktk{kakk;t;;Y;;l;k;44rtrtk;rr{rt4k YY44rtkkYY4444kY444r;f44r/4rtrtrtrtirtYrt4444;4k;;V4t44444444444444444444 <br /> SECTION 2 - To be filled out bynntwak^^removal wont-actors:' <br /> Tank Removal Contractor: �1( Jam' ( (iy�/VI N J►NarJrA L <br /> Addrtss � Cf(L S Df�,f; (=j (2 . Ciry:Lt !�7gs zip:_ '57(p.),Phone p: ( /I6 ) l CJI- '13V Dare Tank Removed: <br /> ..........wi/.4ssi/44/4/rss4i{i.Ff....i4.i..af4....4.f.*,...ff.i.t..fi.a.tf.i.rf 4/Ya44/{{4/f4/4Yr44i/4//Y/V44 <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: TZAt"5 ECJVt!Lori►xG ht— q <br /> Addressj1/� bd- >. y�ll/�L (Zp. City: W__ � zip: <br /> Phone <br /> Authorized representative of contractor certifying through signmutc below that the tank has been decontaminated in as approved <br /> manner as requited by Cal EPA. 'TD j je U, (pLeqyrt!j W At>.> <br /> Name: Title: Signature: Daze <br /> •....«.«4«k/aaa YrraHtrrtrtr/rrtrt/rYrrrtar!lrrrrtrtarrrrrrr!/k;arakrrtrrra+YararVrtt4a/rrY44ara{titl«Yar4f ft{if <br /> SECTION 4 - To be signed and dared by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: / /c(�7✓6�� <br /> Address: � ��7 J�N /Cgfi�f C, City:_ zip: <br /> Phonc #. <br /> Date Tarok Received: T r-13 A . <br /> Name: Title: Signature:__- Date <br /> v...w..f+i.4+4ff ifa4.e{i;.as{.rt+fR«r44rt4.trwaf/.4isaa.4.M1+Fira.«T..re.+«a...+..r/4+,«r«w4r4r.IttM1rt.M1.'Y+.'«t <br /> EH 23 046 (Rcvised 9/11/96) Page 10 <br />