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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 form is completed and returned. <br /> FACILITY NAME: BEACON 4'4Y 2 <br /> FACILITY ADDRESS: 470 IV. MAIN 57' AMAA/TECA <br /> TANK ID #39 - i � 0- <br /> TANK SIZE: /0000 PREVIOUS TANK CONTENTS: a64SOL c- <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_ J N 5 C ON 5 rRye rroN <br /> Address: 82400 15 g5NAW city: C"V1S Zip: <br /> Phone H: ( �I ) Z9/ 174 Date Tank Removed: 10—I 5-98 <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: JAYS Gan/5rRUCTION <br /> Address: l Zt70 E• SN Ate/ City: C t_0 V 15 zip: 9 3 <br /> Phone #: ( x/.09 ) 291 (746 <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 /> FacilityName: CLOL06Y CONTROL 1AIPOT4165 <br /> Address: 255 PARR BL. city:lelcH w ,,VO Zip: 9¢801 <br /> Phone N: ( 510 <br /> Date Tank Received: <br /> Name: Tide: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />