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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 <br /> with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: 5 rOGAe-TDN rE,QJliAvgL $ e,R57'eAZ✓ ,42411-Q::'"%-0 <br /> FACILITY ADDRESS: 1330 Al ?.r Rko <br /> TANK ID #39 - TANK SIZE: /O,UDO PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: OGdF <br /> Address: 333D �f47MAP.T City:_ zip: ,96,Zo6 <br /> Phone #: ( Z1J9 )-�liQz 'S/ � Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: 3330 ,KOr1//l cO4147— City: ; _ Zip: 96M24 <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. pp <br /> Name: &G/29t Title: aMAI _ SignatureDate /O- <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�.1 <br /> Facility Name: S/ Sr7£T L 'el �j5L 4 4 <br /> Address: //3 LO T -- - _ City:,/L1,yr.,•o eo&ur-4 Zip: 95-71{7— <br /> Phone#: ( 9��i ) 4u5--67WO 0 <br /> Dau Tank Received: <br /> Name: Title: Signature: Date <br /> *r��***�w*****r*�***■��MM***********r*+�**s*****+►**�****.*s**********+r*****,r***s****s***sw�****�**:***.**s <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />