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0 <br />0 <br />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'tdnk affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: -7- Efe,v,_ '�; -I,�e_ ZZ3-7 - 37 fIgO <br />FACILITY ADDRESS: kACi L(3 5. 5 i?_i . �t 5 OGi4SUvti) . CA <br />TANK ID 1139 - a_t)rANK SIZE:_ 10� ago PREVIOUS TANK CONTENTS: <br />Ort###+#i#rtrtt#t4##ikk#k####iii##kiiikt###tii##tkk#4#i#ii#ki#iiki####i#t##i###i#ii##t###ktirt4#i#i#ki##itt##i# <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: t ✓v yw 3V J kcal ZA_ , <br />c <br />Address: LM (6 lz.,ss,e,1I IZ>s !3 a city: (�IjL u Zip: Wyq 988-7S' <br />Phone a: (Nz�-) 35 5' - 2 e Z (o Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: M rv.,...., - . <br />Address: City: t3a /# a % Q Zip:_5'_ 33— ,_ <br />Phone N:(o( G I ) _ 393—(/ 5-f <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Title: Signature: Date <br />kWiYWi4kiiiiik4Y#WYikk4Wki##iW#Y#YriYYWWrtkitWkki�kW�k#M�irt#YY�tM�itkYkttikWX�kikkYWY##ttiiWYki4tt4#Yk#Y#Yii#Y#MikkF <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: 6r,:,56,, d- 0S R <br />Address: l 1 U CJd% / i. F 1 5-(- City: I364c Zip: <br />Phone d: f <br />Date Tank <br />Name: Title: Signature: Date <br />EH 23 046 (Revised 08/13/99) Page 10 <br />