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I � ` <br /> SAN JOAQ+ LY COUNTY PUBLIC HEALTH SERVICES <br /> ENS:2ONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - Public Health Services Environn:eaal Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracki::g Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the d isposal or recycling facility . The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME : <br /> FACILITY ADDRESS : (QO I o . EA� � <br /> TANK ID #39 - TANK SIZE : 410 0"0 PREVIOUS TANK CONTENTS : LJ ICAO¢I 00 <br /> SECTION 2 - To be filled out by tank removai contractor. <br /> Tank Removal Coatractor:E y&e"A ) J «i I r s�Y7Zd e& <br /> Address : m L1 � LDt� �/< k%l� City : Zip: 9$ � <br /> Phone k: ( ZvOt ) 7 j(Xl ?:.SSS _ Date Tank Removed: <br /> #####WWW#######*##x*##x #W**##*WWW*##W* k->• ± ++k######x##*+**x#*#W####W#+x*x###*###++*#**#*#######xxx*+xW+###+* <br /> SECTION 3 - To be filled out by contractor " d ,:contaminating tank" : / <br /> Tank Decontamination Contractor. <br /> -'s j r�r_:ref t� � ((IGPi H ! c <br /> Address: lO _ Ci ty:,�3. -yrck rnj Zip: <br /> r <br /> 9s� s <br /> Phone q: (C <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: aCynilrptiJT� / <br /> Address : �QD � 6r�. L (Jy `LAnrC,i �gje City :%/2CAl� Zip: <br /> Phone q: <br /> Date Tank Received: <br /> Name: Title : Signature: Date <br /> #####WWrtW#W####+W#WW*W###W########W##** • xW###W#*###############x#WWWW#######+W#W#x####+W#*W##*WWW#####x+ <br /> EH 23 046 (Revised 10/ 19/98) Page 10 <br />