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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 /> $ <br /> FACILITY NAME: T &+C— <br /> FACILITY ADDRESS: z T1, k,(OU xr� ,y.1 ReJ3cs �44*_Lx_)A_y/ Iellu_ ( <br /> TANK ID#39 2_3L7t9cW 7073 TANK SIZE: 900 U PREVIOUS TANK CONTENTS:R <br /> t:UPU <br /> SECTION 2 -To be filled out <br /> by tank removal contractor: <br /> Tank Removal Contractor: K 20F�+L E2� /VG <br /> Address: (fAe'r-,N- r /I'VE• City: Nc_-� edZip: lj3�2S <br /> Phone#: ( 554) Z& Date Tank Removed: O 3 (A <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: LAST _�s 7-0 fie TIL0*'N5,05V/0re;0 <br /> Address: IA140,e/ S GU/�STA' /l9/�itJ/FEST' City: Zip: <br /> Phone#: ( ) <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 /> i <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 /> j Facility Name: t <br /> Address: City: `,�/�?9�, <br /> ! Zip: <br /> S59) 3 64 - 9 // <br /> Phone#: ( /r�X'774(a5� <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 08/13/99) Page 10 <br /> I <br />