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SAI .OAQUIN COUNTY PUBLIC HEALTH SL__i10ES <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 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 l l-7-'um �../ht° S <br /> FACILITY ADDRESS: ,3400 /V&7)/7 /V <br /> TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out by tank removal contractor: AA <br /> Tank Removal Contractor: f(ayn/irl- El(awilhd <br /> Address: .G&%Or�QI� City: /,OQY1 Zip: &1A(4& <br /> Phone#: ( �9 ) 5y9' �7 Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank":,l <br /> Tank Decontamination Contractor: <br /> Address: City: /�(�/�/ Zip: 9j <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: - <br /> _ ``, Ch M9 <br /> Address: N'' �.J'1 l E���d1Ciry: _ Zip: <br /> Phone #: ( —/-3 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />