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SAN JOAQI=LV COUNTY PUBLIC HEALTH SERVICES <br /> EN"v'IRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Services Enviroruncntal Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracki::;; Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by thesposal or recycling facility . The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME : <br /> FACILITY ADDRESS : «O l z p _ _ Ek� t�:l c T <br /> TANK ID #39 - TANK SIZE : dyvVD PREVIOUS TANK CONTENTS : ( poLr( � <br /> SECTION 2 - To be filled out by tank removal ::ontractor: <br /> Tank Removal Coorntracttorr�Lfn'r /�V%j _�I reS;1�70j (rej - y <br /> Address : � lDr� CA00T Ciry :,37CcK , 2 � Zip: oa <br /> Phone # : ( ) Y��! �ci� Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor " decontaminating tank" : / <br /> Tank Decontamination Contractor: SniC7!,le M7 j WlceiahwlyAr el9 �3 �! ('_ <br /> Address : Q � 14L _ GL Lt o e4_ �Lk City:s-y c�W(� Zip : c'sw C s� <br /> Phone #: <br /> Authorized representative of contractor certifyin 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 /> i <br /> SECTION 4 - To be signed and dated by an acd:orized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping . <br /> I <br /> Facility Name: L// �E� ?' YOJILIeAlT / <br /> Address : f) LU, <br /> ,,-i` 'Tr City: Zip: L,7 �l <br /> Phone #: <br /> Date Tank Received: <br /> Name: _Title: _ Signature: Date <br /> i <br /> EH 23 046 (Revised 10/ 19/98) Page 10 <br /> i <br /> f <br />