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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENWIRONMENTA L HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TR.ACTUNG RECORD j <br /> i <br /> r <br /> � If <br /> + <br /> SECTION i - Public Health Services lrnvironmetttal Health.Division Tank Tracking Sheet shall accompany eaet tank fixed <br /> with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Enviroupental I alth <br /> Division within 30 dans of acceptance of the tank: by the disposal or recycling facility. The permit holder is r sponsiblb for <br /> ensuring that this forth is completed and resumed. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: E <br /> TANK ID 1f39 TANK SIZE: PREVIOUS TANK CONTENT5. <br /> .w«+•++��*.x���r��w****R�xr��*w�+�h�*�s�rxx****�*��xwww�h�*t.****,��a**x*:��+++k+kwwx*t**s*x*w�*wwr{w�*x�**. **���*w <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> ' R <br /> Tawk Removal Coutractor: <br /> r <br /> Address: I <br /> City: Zip: I <br /> Phone #: t ) Date Tattle Removed: <br /> I <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> f <br /> Address: <br /> City: Zip: <br /> Phone #: <br /> Authorized representative of contractor certifying throu-eb signature below that the tank- has been decontaminated�n an ap roved <br /> manner as required by Cal EPA. <br /> I <br /> Name: Title: Signature: Dare <br /> c <br /> SECTION Q - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting; tank and/or piping. s <br /> Facility Name: <br /> Address: <br /> City: Zip: <br /> Phone n"_ ( ) <br /> E <br /> Date Tans: Deceived: <br /> Name: Title: Signature: Date I i <br /> I 1 <br /> EH 23 W (]devised 9/11/9ft) I <br /> Page LO <br /> i <br /> { <br /> p <br /> 0T ",� hh,JTS.9:3606.T 0i 2,66T-60-�:T <br />