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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 resumed 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 form is completed and returned. <br /> FACILITY NAME: layILa( �prJlcz b <br /> FACILITY ADDRESS: 00,75: <br /> TANK ID Y39 - I 7- TANK SIZE: tot e�O PREVIOUS TANK CONTENTS: J4? 4� <br /> SECTION 2 - To be filled out by /tank removal contractor: <br /> Tank Removal Contractor-, Oktx ro A,' S-t RUC_ <br /> Address: . Q aea /Floe City: I Ym5L 7_Zip: 9�` 3 � CO B <br /> Phone #: ( CI 8 3Z - 6-0 / Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: 5TOxL <br /> P. <br /> Cm t s7 a c� a/U <br /> Address:i}� 0 . 5oSC. 460A City: TYo�K Zip:r?i:_:3 /4702) <br /> Phone lt: (7 04 -SO// Z <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by JCal EPA. D <br /> Name: %%� Title: Signature 0 6 Date 9-1//•-9D <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: U)eS-r CoQ Yt <br /> Address: OD X/ ulna L ur/t City: Tuv nor k Zip: �T53 60 <br /> Phone H: (� 6168 93 ,7S <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> }W##WWWW#WWWWrtW Wrt#W*WWWrt*WMMWWWrt#W#**Wrti#WW*#####W WsiirtWrt#WWWW##*W#iWiWW##WWiirtrtWWWiWWiWWi###WiWW##W Wrt### <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />