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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: -7 — 1✓(P,}_ S Ise _ Z -Z37 — . 3 Z i c, O FACILITY ADDRESS: L{C%t-j-5 5, a,A 9Ct SToC�<-4o✓J, �,A TANK ID #39 -6X _TANK SIZE:_: �4D� _PREVIOUS TANK CONTENTS: SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: —G C_ Ler ✓, , in,. 1� Address: 1Z t3 City: �Yt.,(� % (-o u Zip; ?8z -77 - Phone ll: (�(2- " ) 35 5 - - t Z (o Date Tank Removed #}##kk}#t##+##W+##fi#}W}M+##+M#fik W#MWkk4#kW4}#WWW#+M+W#k#W#rt#+tWWk+WM}##}WMM#WWfiM++W##k Wort#WWWWk#}WWW#}MfiWM# SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: (l-� y h,1tra rv�-L , i Address: 3 (u� Ma 5 {ve e /� t City: c'; % J, /J Zip: 43333ocrz -- Phone //: (GG I ) 39 3 —( 1 5` 1 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Name: Title: Signature: Date #W#MW##ifiWiiiiiiiik#ii4Wtkikikk+#ik+i}Wi##Wkki##k}#kk4#}WkkrtfifiWWWkM#fikWfikW#4ktWM##tWWfi#W#fik}WW+W##MM}W##k+k SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: C_ro 5 L + look- .3, Address: ((. I U cies a -7. (-k, 5 i City: L (Sc Zip: Phone N: ( ) Date Tank Title: Signature: Date EH 23 046 (Revised 08/13/99) Page 10