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12/18/98 FRI 09:33 FAX 3106096304 RHL DESIGN GROUP RHL PETALU-AA [a011 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACIONG RECORD <br /> SECTION I - 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: TF—:-X P,co <br /> FACILITY ADDRESS: "i O I4 • CV,aw-k er WcLW <br /> TANK ID#39 - jD5 5'C& TANK SIZE: l U,000 PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: k- E L 1 <br /> Lm-�ks l 0 r�STR 1A� ly,n <br /> Address: [400 OLID CDnS�o R.Q City: Ne_�QAv' Q ip: q 132 b <br /> Phone #: (9 I(o } L b- $s Date Tank Removed: <br /> SECTION 3 - To be Cilled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: C rosbs,, <br /> Address: `6 W �)o N neke q 'ST. City: Oct k.tc.n0 Zip: <br /> Phone #: f 5 I ('0 3 - 0 33 l,o <br /> Authorized representative of contractor certifying duough 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: C ru��� Uy er7-04--\ <br /> Address: �o�j O �� 11'�� ST. City:LON 6 aoc k Zip: C1 <br /> Phone #: ( <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />