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r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> f. <br /> f i! <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 /> ensuring that this form is completed and returned. <br /> _ t <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANK ID #39 - pZ `0I TANK SIZE:/.4100 PREVIOUS TANK CONTENTS:_0 ' <br /> I, <br /> SECTION 2 - To be filled out by tank removal contractor: r <br /> I� <br /> 1� <br /> Tank Removal Contractor:.5r-,o c4�-tyh/�{�,.��i�j-��V� � (fe" �yyGt <br /> Q <br /> Address: p O r Y'- =�A Zip: ! <br /> Phone #: Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": ik <br /> Tank Decontamination Contractor•. -'moo g <br /> n-�lecrei � ur� C C. <br /> Address: O City;��C`rzr Zip: <br /> Phone #: L <br /> :g <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 /> N Title: 14 <br /> Signature. Date <br /> !E <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 /> F <br /> Facility Name:<n-,41— C'©0-ST'~ ,Z;4C <br /> Address: /T qU 4XL, � e� .,....., City:' 6t AL4 C ^_Zip: <br /> Date Tank ceived: <br /> Name: A Title: ignature:,� ate <br /> EH 23 046 (Revised 9/11/95) Page 10 <br /> ;4 . <br />