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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONiVIENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each'tank affixed with its site identification number. The Tank Tracking Sheet is to be remmed to Public Health Services Environmental Health Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and/returned. ( , - FACILITY NAME: P&+C FACILITY ADDRESS: 2 4-081 '>uuTI tj-1 ',toUT-A-i.,J Ye J)ts �444_LJA"( '4n� TANK ID#39 Z317t917 0-2b!-TANK SIZE: 3, (�Q l tZ�2 NPREVIOUS TANK CONTENTS: Vo Z SECTION 2-To be filled out by tank removal contractor: Tank Removal Contractor: Address:- S, �'HEST/VU1- /AVE. City: F2ESAfgo Zip: Phone X: (i5Sgq ) Z 3 jz- 3 F4,C/ Date Tank Removed: Z SECTION 3 -To be filled out by contractor "decontaminating tank": iI Tank Decontamination Contractor: //A 4157- TlJ /3E 7J44A) SP,nveRW Glii/JJE,e Address: /�4�/LODsIS uJ A S rE sl!¢.v/FEST City: Zip: Phone N: ( ) Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. i Name: Title: Signature: Date ii}Y##rt#####iTM###i+#Y#Yi4Mi4#Y#i#ii#}i#iYi##i}i#iY}#i##ii#+#i#ik###Wi*4##*Yi#Y}I+YYii}#}##i4Yii#iiYYY+W#} SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. j Facility Name: 7-/2oL til 4W 5 Trz 1E5 Address: z 5-15' /'�'/iQ/O 0Lt/t,7 . City: tetC{- CA/0 Zip: 9y80/ Phone A: (5-/0 ) 235— /393 Date Tank Received: I I Name: Title: Signature: Date EH 23 046 (Revised 08/13/99) Page 10 I