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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 tank 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 - ECe� - '� 4,,�z ZZ 3'7 - -32 tII r, Q <br />FACILITY ADDRESS:—'A Sy3 `�, S -"+e 12� JC1 57ock4-Dvj ()rq <br />TANK ID #39 -d /_TANK SIZE:_ _PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by /tank removal contractor: <br />Tank Removal Contractor: _ G%GLer 1L.-t.,yt✓,n Vim.., J-" ( �-Jt1.oi JA, <br />Address: t -P /lo lz-, 5-,, IZ =�, � 11 Ci .�/�, � 1-�- <br />city: i'I'1 u Zip: 1/-1 i6'Z7S <br />Phone #: (qZ2 - ) 3S S - Z Z (o Date Tank Removed: <br />#44##rt####W###r##Y#}#Y####4##W#Ort#r###*k###k##k}#####W##rtr###r##k##}rt##########4#+#Wrt##+######W4########### <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor:r0, r,, 1� i <br />Address: 3 I0u Maw,, 5{ ez <br />'f- City: 3� /,.e_.a truu / 1 Zip: '333x <br />Phone #: (&(o I ) 34 -� -1 15- 1 <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 />Name: Title: Signature: Date <br />kktk4#kkk44kkk4kkk##k4kk4r#k4k4kkkkk4kkkkk Wkkk4kkkYkkkkkkkkkk#kkk#kkkkkkk#kkkWkkkikkkkkkk#4Wk#kWkk#kkYkkkkk <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: C r4,5 <br />Address: iCe t U CJ'e.S 1 -7. � ST Cit / <br />Y:�.v-� 324c Zip: <br />Phone #: f 1 <br />Date Tank Received: <br />Title: Signature: Date <br />EH 23 046 (Revised 08/13/99) Page 10 <br />