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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 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: BEAC o N 4412 <br /> FACILITY ADDRESS: 470 N. MAIN ST-. /vl ANrEcA <br /> TANK ID #39 - TANK SIZE:3 75 6 AL• PREVIOUS TANK CONTENTS: L/NKiyo WIV. <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: JN S C ON STR UC T i D N <br /> Address: ! 200 C• 5HA W <br /> q city: C LOV15 zip: ?-36(l <br /> Phone k: ( F I )2 q 1 /746 Date Tank Removed: 1(-13-181 <br /> SECTION 3 - To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: J/V S CDN 5TAUC T(0/,l <br /> Address: 7ZOO e- 5 HA VV <br /> City: Cl-D V1 s zip: <br /> Phone#: Z( 0 9 ) 2-9 9 74 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date <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: EC11t.D G y G0Nr ?,0L IND U51-AI Cr S <br /> Address: Z55 1 AR9 &L . Citv: Rkr-4M ON D zip: qq- <br /> $0 <br /> Phone N: ( 510 12-S5 i'Ij q 3 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />