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r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> • UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ***#tt+***+*#4*#iwwwW**444*t#####itwtw4t#t#w#tt4##www*iw4##rtwWWwrt#i##**wt*rtwW*tWwww+*#ttwttwt4******#tw###w <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. 1 <br /> FACILITY NAME: �1►j�' �—v o�� S c�iQ -- �t`I C <br /> 1 <br /> FACILITY ADDRESS: ZL{Z1 W R5r <br /> TANK ID #39 - TANK SIZE: 10ooa G,pl PREVIOUS TANK CONTENTS: P it5t� <br /> 4WW*Wirt*rtrtrt*rt**W*WWW+W#WW444##4++4WWW##ii#44#4#4t4trtWrt#itti44444#i###444#rt4rt4+rtrtWW#W#i■#4rtrt#tit#444WW#i4#rt# <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: � ,,,, <br /> -+ L— ZtJ C_ <br /> Address:apyo Su,�C yoo City: t/o,cc,v, �e Zip: QS(o$7 <br /> Phoney: (101 ) 44(a Date Tank Removed: <br /> *#Ort+t4rt#####+##4#4##4#trt#W*Wtw#w#W4+4#trt44+itWW*WW#w#4#44#+########4#*4#W4WtWwWw#w#+#iWrttwWww4##+rtW*wti4#* <br /> • SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone N: (� <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 /> Facility Name: <br /> Address: a5r City: -24 Zip: <br /> Phone N: ( 5 Ic, ) a3�= 1393 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> *##t*#w#W*4##**#4##+444444#4**####444***w+#4#4t#tW#+4#**t#ww#+##+**+tttwwww4#####t*ww4#4rtwwttWw#**t#W**rtrt <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />