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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: BEAtOIV 4& 49Z <br /> FACILITY ADDRESS: 470 /1- MA 11V 5T. 44,4A/TE ,4 <br /> t <br /> TANK ID /139 - 7`f�_TANK SIZE: 1067aO PREVIOUS TANK CONTENTS:Gif50c//VE <br /> SECTION 2 - To be filled outby tank removal contractor: <br /> Tank Removal Contractor: JN5 40iV5TR✓z ria/,// <br /> Address: 200 E. 5//A L- <br /> �,, city: c Z-0 vis Zip: <br /> Phone N: ( ?09 ) 299 1749' Date Tank Removed: /49-15-yX <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: J/vS r0'✓5TR✓<I70i1 <br /> Address: 9200 E • 5)Y,q in/ Cit 6—4.0 Vt $ <br /> Phone k: ( G09 ) �u 17*& <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: <br /> Dale <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: Ec-0`06% CQArrA01- //VD ✓STjClE5 <br /> Address: 25-5; PMIZ 6L . o <br /> City: Zip: 9480/ <br /> R1�H.rt /vD <br /> Phone N: (-510 ) 7,35 313 <br /> Date Tank Received: <br /> Name: Title: <br /> Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />