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0 <br />Ll <br />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 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. MFV-K)5e D1ST%Z i Gu T �� c1.: t)ETPO-T <br />FACILITY NAME: DE —1 )Cr. 2 6,1 ST CS Pbum )� !��B Q .fir q GtA 1 O S[1Qi QC• Dr--(DC)T <br />FACILITY ADDRESS: 9 cc F, <br />TANK ID #39 - Jg�� TANK SIZE:(�PREVIOUS TANK CONTENTS: N CISE� <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: P ®-rQ , <br />Address:1 A 1 �DTF . City: Slgit ra"oto Zip: <br />Phone #: (914�1) �Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: <br />Phone #: <br />City: <br />Zip: <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 />Nom: Title: <br />Signature: <br />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 />Address: <br />Phone #: ( )e <br />Date Tank Received: <br />Name: Title: <br />City: <br />Signature: <br />EH 23 046 (Revised 08/13/99) Page 10 <br />Zip: <br />Date <br />