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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 /> FACILITY NAME : <br /> C � <br /> w \ Not�,- � <br /> FACILITY ADDRESS : RO L o � <br /> TANK ID #39 - 10 TANK SIZE : 0017 PREVIOUS TANK CONTENTS : I4?4 LEAD <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractort.5 '-`Q <br /> Address : 3(93 MO L 1 / IIOt� �� t%(� City :,!9r � Zip: �1S � <br /> Phone #: ( L�1 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination Contractor: SZC LT(IrU zA .7�0 C <br /> Address : 96 t, �/ n/! G c/ ( D / F �sT77J�F� City: Zip: 9 CJS <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 /> 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 : 6�46, l 1'���Q� <br /> Address :_�� City: /2'B Zip: <br /> Phone #: <br /> Date Tank Received: <br /> Name : Title: Signature: Date <br /> EH 23 046 (Revised 10/ 19/98) Page 10 <br />