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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 <br /> with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> Division within 30 dam 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. <br /> FACILITY NAME: <br /> FACILITY ADDRESS:_ c.rJV <br /> TANK ID #39 - b 1 TANK SIZE: PREVIOUS TANK CONTENTS: N-DA <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: bl t <br /> Address: t ^ MLA L A City: - ` ip: 'J-5 <br /> Phone #: V� 9 151 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": `� '�? <br /> Tank Decontamination Contractor: �L-' 1 El ` &E—Z 1�`�� 1� sf-^'1 +��' <br /> Address: ! 1)t"JL t, 0 L..1 Cit: r-�'�'}' ice.` r~NZip:— <br /> Phone #: O <br /> 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: Daze <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: <br /> b b A-f city:T I F'ti'.1 c-t ' 1 C41p: �JtJT— <br /> Phone #: ( } 53 7 41�� <br /> Date Tank Received: <br /> Name: Tide: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />