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SAN J( ,2UIN COUNTY PUBLIC HEALTH SERV. S <br /> ENVIRONMIISTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> i44#fi#44rt*4t4+WW#W4W4rt#4#4trtttt#4*#4#W4rt##t*4W4#44444#W#t4444#WWrtW#rt#Wrt44#4#4444fi#rt*4W*#444##**444*#++#+4;fi <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 retuned 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: 3/— S�� // -� / I <br /> FACILITY ADDRESS: ( 2Jc,2, G/fI ��2 LOO ,�0. S7,0 <br /> TANK ID #39 - Q 1'� 002 TANK SIZE: 4000 PREVIOUS TANK CONTENTS: <br /> ►rt*44444t44tfifi#+444444444rtrttrfi4fi#rt#tt44r#+#W#4rfit44i444rt4r4srtt*tr+**4rt4#+t+**4##4t*#4W4r4tfi#*4w#i+��4rtrt*� <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: J , ,"t <br /> Address: �_3 /�/ /✓, C lcz� %U/• City: C Zip: �d <br /> Phone 9: ( �B%) T �� 3���� Date Tank Removed: <br /> 444#44444#4#rtr4rt#ttrtrtt++4fi4fi+4+#++++iM4444rt4#4#*##t**i►*#4#W#r#*Ort#rttrt+***Wortt+#+*+W#rt4+t#+WWW4rt+*#rtrtw4+*## <br /> SECTION 3 - To be filled out by contractor "decontaminating tank":: <br /> Tank Decontamination Contractor. <br /> Address:.3' ,S 7 A), city: �r�( Zip: <br /> Phone N: ( 2.4 07) c3 s� <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as requiredbyCal EPA- <br /> Name: Title: ��f���F�t��Signanue: Date <br /> 4444+fi#t#4W*+++*+#444+*+4i#+t44*4#44ttt4##*t#4*fi44tirtorr►ti444rrr4#W44rtt4444r4ir#trtt4**i4444irtrr#44rfi*4r4rt <br /> SECTION 4- To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank <br /> /and/or piping. <br /> Facility Name: 5���1i �Z�/� ��£� P/?L-)dq(f 7 f _ <br /> Address:_ ,� �G�© f D�S'G�/ �� f�/�. City: C C[7� � Zip: 5 ;7 Z"2 <br /> Phone k: ( ) 7�S ` .O �� <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> *444i#44raW44+#4W#+4++44rt++rt4t44+r4*+rt+4W#4##rt#rt++4fi*4++r4firt#4#+i4++4t4#4##*+W#4#*fi4+rt4+4444#!##rt*+++r#fi+ <br /> EH 23 046 (Revised 10/19/96) Page 10 <br />