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SAr. JOAQUIN COUNTY PUBLIC HEALTH Sr,RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING 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: goore Tram Zln& S <br /> FACILITY ADDRESS: .3490 /V2Q)i t_7 /V SII��TtJ/! C� <br /> TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out by tank removal <br /> contractor: <br /> Tank Removal Contractor: f u(�lf f'�- L-1(4 <br /> Address: .G�7 Or�QI� City: &OW Zip: 7� 0 <br /> Phone ft: ( � l ) 5y9-, 31/7 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: f/Un Zip: 9� <br /> Phone #: (�) !/ -.z5 <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: <br /> Address: f��D ,LV/�AIOmU City: Za-do[,(' Zip: <br /> Phone a: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />