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SA-N JOAQULN COUNTY PUBLIC HEALTH SERVICES <br /> ENYERONIIENTAL HEALTH DIVISION <br /> UN, DERGROUN-D STORAGE TAIN-K DISPOSITION TRACI%TgG RECORD <br /> .........................................***..*................_........._...,._.........._..._.. <br /> SECTION I • Pubhc Health Services Environmental Health Division Tank Tracking Shcet shall accor::pany each tank Y - <br /> aftixed <br /> 2h its sive identi[ication number. The Tank Tracking Sheet is to be returned to Public Health Se-rices Et:vimrunema l H_Jt <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is resvorsibie for <br /> easurit:s :hai this form is completed and remmed. <br /> ,, <br /> FACILITY .ADDRESS: x,11 <br /> TANK ID =3Q p7, TANK SIZE: �b ��t• PREV10[:S TANK C 0 NT ENTS:—�k��lrI.'� <br /> ..................... .................... .................. <br /> SECTION ? - To be tilled out by tank removal contractor: = -._,_. <br /> T 2aik Rcmoval Contra?ctllo''r: <br /> �.acress _� J�V <br /> Prone = �) 9�4] 3IS] ^ Date Tank Removed: D <br /> ..__...,..,....................,.....__._....._*....*...*.._.....__.....-___-_.._--____._.....___.._.,........ <br /> SECTION 3 - To be ;died out by contractor "decontaminatii—ng� tank": <br /> 7�, <br /> L, <br /> a. u�. ec .epresc.^.t1t �'e of con(.-3c-or ce:ziNing through signature below that the tank has bet^ Cecu ,:ed in <br /> :.:=Mie- required by Cal EPA. <br /> Name: Titie: Signature: Date +� <br /> SECTION 4 To be signed and dated by an authorized representative of cite treatment, staraae,. or dis;.csal fac:iiry <br /> accepting tank and/or piping. <br /> ac:lid N �-e14c <br /> Date T�_k Received: <br /> Na--- Sienature Da: <br /> ............. ................................... <br /> *.*............... <br /> ..... .............. <br /> ............ <br /> ._. <br /> _.. ,r 0=6 (Revised 9111/96) Page 10 <br />