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r <br /> a. <br /> SAN JOAQUII� COUNTY PUBLIC HEALTH SERVICES <br /> ENvIRONN ENTAL 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: <br /> FACILITY ADDRESS: `fie ( rc-e <br /> TANK ID #39 - TANK SIZE: S® PREVIOUS TANK CONTENTS: Lr�CSCR <br /> kaxxak aK�laxak aK�k ajc%eak>k ak ak ak ap ak ak�k iia ala ak ak aK ak akak as aK aK ak kt akak ape ode ak akxak is ak qe akakaK akxak kaak ak ak ak ak ak ak MaK akak kc>k Mak akxak ka�laak ks ak ka ak aicakaa akak ak akxxxa.akakxaz akak ak sc>k xk�aK ak yc ak akx akx <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: RAIA Ln,-0 &A--_ _-rte 4-4 <br /> Address: -e City: Lze4,k rs Zip: <br /> Phone #: ( �T l(� ) S�- '� Date Tank Removed: <br /> *ai as as x aic ak%yc>k ra is ak�k xak�ak ak*>k rc ke*ka*ala ak ak ak ak alc aia>k ak aK ak*>k ak ya ak ak ak ye akak akM>oa ya�kak#ka ak ak ak*ak qa akak akak ak*ak�k ak*ak ak>k ala>k ak*aIc*ak ak ak a'c x x>k as qa ak ak ak akaKakakak ak ak�K>k x x ka ak ax>k <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": AJ64 <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <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: <br /> Title: Signature: Date <br /> �kak#akakak ak>k ak ak*ak ak*ak>kak#ak ya>k***ak ak xaak ak>kakak akak yank akale akak akak aka{c ak ak ak ak ak*akakakakak yaakak akaK>k*ak�pakakaK akak ak a0cakakakakak akakakakakak akak alaakakak akak*akak akak>kakakak ak*ak*ak ala ak* <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 /> ✓f City: / Zip: <br /> Address: 11 <br /> Phone #: Cr) ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> *********akak%a#ak**akakak***********axak****�akakak MMak***********ak*****akakakakakakakakkwkakakakak#akaka«*********>kak****�*akak***aK***aa <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />