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SAI. JOAQUIN COUNTY PUBLIC HEALTH SL-.VICES <br /> ENVIRONMENTAL HEALTH DMSION <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 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: gcorc TruM bn& S <br /> FACILITY ADDRESS: 3400 /VQuJ bI7 /CU 6)�XC2T n Cl� <br /> TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: nlj y <br /> #«#«#«#«####**rtrt##rtrtrtrt#rtrtrtrtrtrt##rt###rt#«#rrt#*##rrt######rt####*+#*#**rtrtrr##rrrt###*rtrtrt#**####*+k*#*#**f#«#rt«#«### <br /> SECTION 2 - To be filled out by tank removalcontractor:contractoor: <br /> Tank Removal Contractor: /(,i.lallYr L—x(,a I <br /> .-- <br /> Address: 9 Ormr? City: Zip: &1A(4& <br /> Phone !t: ( �9 ) 5y9J-�_3-'17 Date Tank Removed: <br /> ###rrt#«rt#rtrtrtrtrtrt,hrtrt#rtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrt##rtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrt#rtrtrtrtrtrtrtrtrtrtrtrtrt.rtrtrt#rtrtrtrtrtrtrtrtrtrtrtrtrt#*+#*rrtrtrt**** <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: 10&L �dgt&) <br /> Address: City: fl'/,O w Zip: 9� <br /> Phone /l: <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: lC� .af/m ft/ <br /> Address: -��`f� L 1/f7QJLIl�U City: 7iQ//�0"T Zip: &3,po <br /> Phone #: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ##««#*««#rtrt#**�##M#!«««#rt,r«s#««#««k«!*1k1M«*««■««■«+M#«*#«*#«*�«#F*rt«rt«iF#«#«#««####+�#«#rtr#*«««*F#•««M#«««#*at <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />