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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 <br /> with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this formis completed and returned. <br /> FACILITY NAME: f p � I')�T ��PF tir <br /> FACILITY ADDRESS: . .01 S ©v W I so r) Wo, <br /> TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: R .,1 G <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: AaAjc, EdIvilGAMEnidJ01 <br /> Address: 0 VA—City: S L c-K+,o n Zip: 95 Z oy`5 <br /> Phone #: ( Zn } U b7 / co _ Date Tank Removed: <br /> MMMfiM*kik k*k k k ft K ass�kk*ya:aycMMaflelt M*MMIK�aK*��r�ytgc**M*:*k+k k akak*aiMMfkfW Yt XON aK klk aM�x*k*k a#k k K k:mat Mat arMMM MfIc***�[rk�Mxxarx MSF*k*ak <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: A a v "ID C I r <br /> Address: V(Z) C)5 N . ISO n YV /`� City: S IOCjK4,o/) Zip: 9� 2-,P�j <br /> Phone #: ( Z-109 } U 10 O p <br /> Authorized represemative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> S►)�FF- - <br /> Name: Title: G e-QI 15 7 Signature: ate <br /> *�Yk kM*ilk k kMM]kM»EHt Mi Mt lk fk*ilt Mt Mt i}t**k3kDKaKY k�***�MM+F�k:kifi*'*�F kzs#51v M91f Yt Miklkh ii kM*****F k k k ft#k�ak ak***altlkfie Mf9llk+k***ae*My[YMF k k sok k <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: �`1J 0- . — <br /> Address: (j Q )A � & �Q._� City: 1 W��p C �� Zip: <br /> Phone #: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> sMat�MM YM�M M>>k* MSK***M*arrat�Ic k k aka ax*Mk kfi�*�zk MkM���M+kM ih k i fIc Y sok*sok kM F F aacsM M1X 1K 9r'JM**Yas Yak aK�s ok as a'ss Y�xakaacfis�sas�MM <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />