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JOAQUIN COUNTY PUBLIC HEALTH SEICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> 4fi4#i#iffiW#kki##i!!!t}4fitk}tii#R##ifftit##tk#4kt#rt4#Yti#i Wik##+k+#t#!ii}i}i#i Ytt4#i##R44lttik44kktiii YkY+i <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: Y"S — <br /> n <br /> FACILITY ADDRESS: aV^ E�.s 1 he <br /> TANK ID k39- 2 TANK SIZE:201()OC) PREVIOUS TANK CONTENTS: Aj t--St 1 <br /> Yik#WW4kktrt R#t#4k#iW}i Ytk##itis###iRi#WWk####tWk###}i+##W}t#}######k#####44#}###4i#fit#tWt##tWtkkk4ik44Yk#iW <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: V <br /> Address: % City: r '�c.-jp: q4 (� <br /> Phonep: 650) Q52- 655 Date Tank Removed: /"200I /'l; -rCoU <br /> '. kit+Yki#kiiR#i#4Wi#44i#i#rtkk+4i#+kitiirtrt#}}ttikk#kt}ki#}iikk#kWi}R#f#####}#k#ki+#4kik4ktit44#4t#iR}##WYik4t <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone k: ( ) <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 /> lkWtYkfkiik#4t4R4ktkiRf4ltkkYRifi4k}iiWtkki444#i#tttt4k##}Rktkkik#+##4kk4Rk44ti MY44}}#tiktk#}##4##4}###tk4ii <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 /> y— 1 <br /> h <br /> Ir <br /> Facility Name: C6 � <br /> ei <br /> Address: S� g. ^ /UCc -Noyld Zip: <br /> Phone p: //1^7 0 -- 7q 62 — <br /> Date <br /> Tank Received: <br /> Name: Title: Signature: Date <br /> iRtRR4tiifiYk#!ltit#44R#44ktiktiRkiii WikittlF4RWWRiYki#tYtitiii#tfiiiiftti F4Wk#4RRtt#iW#tWiiii4t4i#ti►#iit <br /> EH 23 046 (Revised 08113/99) Page 10 <br /> II <br />