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�%W %..O� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EIYYIRONNj ENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> #�I.•k*####*###%####.iex==######=**x#**#*#i..a.======..x==i•i=...ex....=...=a==..=.. <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 /> easurins that this form is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS:_ m <br /> TANK ID T39 Q !_— TANK SIZE: PREVIOUS TANK CONTENTS: <br /> .............. ata==a. ........#aa= a.s.. .======..a. ..... .............. <br /> SECTION 3 - To be tilled out by tank removal contractor: x <br /> Tank Removal Contractor: <br /> address C� ;k ���L-- l 1 City: L. bks (Aip: �5�6 <br /> (y -- - <br /> Phone } � � � Date Tank Removed: <br /> a==,.r.;���:.s..r.....aa..a a=... =....K•aa�r�.rra..k.h�.#=gaga###*#==i==a==#a=#.ic ..#r..y..s...a..m....=ani==. <br /> SECTIO` 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decon[ami anon Contractor: 71a�Uii- <br /> Address: D L Z� (��� �`{�} 6 Ci[v: Zip: - S361 <br /> Phone = ( ck i 1 14-7 T <br /> Authorized represen(a[ive of contractor certifying through signature below that the [aak has been decontaminated in an aavrovec <br /> ai=er as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> ................. ===a.k. <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: + `_� rn <br /> address: 1Ciry: w✓' ] Zip: <br /> Phone =: � j <br /> Date Tank Received: <br /> Name: Title: S i2nature: Date <br /> ,.gaga......======. ..rt.__.a==#.as . .===aa=. ...y.===.t=a=y.as====aa=a==a==a====a....==aa <br /> EH ?3 0=b (Revised 9/11196) Page 10 <br />