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SAN JWAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION I - 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 <br />FACILITY <br />TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br />SECTION 2 - To he filled out by tank removal, contractor: <br />Tank Removal Contractor: �5i <br />Address: <br />Phone N: <br />Date Tank Removed: <br />Zip: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: �C-pp 404) 4 I7A <br />Address: Pj011�1-- A/o ZL),6A� Ciryzip: lcS-2e1 (� <br />Phone N: (jnrq) <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: <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 <br />Address: <br />Phone a: <br />Date Tank Rec <br />Name: <br />City: Zip: <br />Title: Signature: <br />EH 23 046 (Revised 10/19/98) Page 10 <br />