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SAN JOtv,ZUIN COUNTY PUBLIC HEALTH SERV1.r�S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> rt*rrrrtWr»Wr#rrWirtr#Wrrrrrtrrtrt»W#WrrWW+rrWWi#rtYWrrWrrrr+rtrtWWrr#rt#WrrWWrrrtW#rrtWr#WWrrrWiirrM,#Y,r»»r»#r#Mirtrt+rir <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: <br /> FACILITY ADDRESS:�20 721 C 00 <br /> TANK m #39 - O(`O 3 >O S TANK SIZE: 4"62VO PREVIOUS TANK CONTENTS: <br /> r#i»rrtrrrr»rrtrtrrr##Wrrri,FFrrrrrt#rtrtr,F+Yrtrt#rr#rrWil,rrrrtrrrrWrrrrrrtWWWWrrrtWWWrrr+WWW,1,WWrrrtWWrr#,Frr#»rr»T»��,*W <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 5 / ^'7 /�Yo/ <br /> Address: y � /7� /�, /�L G��✓��� X11/ City: t� 4/� ( Zip: <br /> Phone#: `) 7 �� 3 7 �� Date Tank Removed: <br /> rr»rtWrtrrrirrrt»rtWWrrrtrrt#Ww,WWrrrrrrtrrt#WrWr##W#WirirrrrtWrtrtWWWrW*rrt#rirt#rtiw+r#WrrW+r#,rir#rtWWrt»rWWrrWrWrt#rrr#rt#r <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address:, l3 city: Z �/ Zip: �o <br /> Phone#: <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as requtreddbby Cal EPA. <br /> Name:��4X 2Q—AE Title: �It£S/gs! 7 Signature: Date <br /> +,Wrrrr►+»rrrriirr»»rtr»»»rt+WrWWii,rrr+rrrrrrrrrr»rtrWrrrrtrtrrWrwa,#rWrrtrt#Wrrt*rr»rrtrtrt#Wrrrrrrtrri,rrir»rtWrrrtrrtrr*#* <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 /> Adams: 1 00© fvLS©�/ /� C r//). City: e,�2DoU°- zip: 9S <br /> Phone#: <br /> Dare Tank Received: <br /> Name: Title: Signature: Dare <br /> rrrtirWrt#WWWrri##+**####rWWWririrrWWrW#»rWrrWWr+ir##riiirWrrr#r#rWW#W#+WWW#r#+#WWrr*###WWWWWWii##WWrr#irtWr <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />