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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 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 Envirottmental 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: gore TruM Lines5- <br /> FACILITY ADDRESS: .3400 /VOLl AW7 /HCl S/ j� .Zrn eR <br /> TANK ID 1139 - TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out by tank/removal <br /> contractor: <br /> Tank Removal Contractor: <br /> Address: .GtY l Or��f� City: /,ODYI Zip: Quo <br /> p —, <br /> Phone {1: ( � I ) 5W 4-347 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: QI//'� '5ya '/7/'a <br /> Address: City: fa'p(/�I Zip: 95m <br /> Phone #: <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: CG� t �if2g I� <br /> Address: f 1//7GZJQmC� City: 70--f- Zip: ,53,06 <br /> Phone #: ( q) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />