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SAN j%MQUIN COUNTY PUBLIC HEALTH SERV 4wS <br />ENvIRONmENTAL HEALTH DMSION <br />UNDERGROUND STORAGE TA.NK DISPOSITION TRACKING RECORD <br />rrrw.rrr»a+rrrrY.rlrrr»rrrr.rrrrurrr»urrrrrlrrrrr.rlrwlrrrr.larrrrwrw.rwrwrwrwr.lwoaryvrrrlrrrrrr»rrrrr <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. n <br />FACILITY NAME: My MINI /�lAP- <br />FACILITY ADDRESS: I <br />�I <br />TANK ID /139 TANK SIZE: LD O6 PREVIOUS TANK CONTENTS: <br />rrtrwrrrrw.r•rrtrwwwlrrr.lwrrrrrwrrrr•.arrar..r.rrrr..rrtrrrrra•rrt.YY.rw.rrwrartrrrr.ry.rarr..rrr.rrrrtarrrr.•rw <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal i{{7�����Contractor: C. � rw tr tv'" i2—! " <br />Address: �C �� 1^%``I��(// � l(� City: Zip: �I SZUS <br />Phone //: Date Tank Removed: <br />iiiairiair»irrYiiiii»iri.•niiir•iirrrY..Y.Yr.•iirra.iYrriatiiY4iririir..»»ri»rrrr..ir.rlrrrri.Y»r»r.r>.riii <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: <br />Phone 11: <br />City: <br />Authorized representative of contractor certising through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. /Z / <br />Name: Tide: Signature: Date ` <br />rrY•wr•rrrrtrt..wrr.rlr•wrarwr•rrr.........•r...r*.....r•»rarrYrrt»rlrrr.r+w»r»•rlrw+rrrrrralrrrrrrrYrr»rrr..r <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: /j G <br />-,City: �C Zip: �� 0 <br />7 <br />IV <br />Address <br />Phone k <br />Date i <br />Name: <br />llrrrlrrri..rrrr!!r»rrrrirrlrrlrwr»l.rrirr.!!!lrlrrlarrrrrllrtrrrrlw»rri»irrllrrr!lrla.ltrflrar!llrrrwrlrr <br />EH 23 046 (Revised 10/19/98) Page 10 <br />