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11/02/2001 10:47 9166813,Ul GEOFON INC PAGE 12 <br />SAN 3OAQUIN COUNTY PUBLIC BEATIT11 SERVICES <br />E1�fR0NMENTAL EMALT13 DIVISION <br />UNDtRGROVNID STORAGE TANK IMS ON TRACKING RECORD <br />.»»==.a*=.w»+===rt:»»»»*=w=rt*»»*»*==e,.=.�wr**,*rtrt===*,�*»=w»►=*a*rtrt=*w»»«w***�,*s»=.»»»:_*»*___»»*«___*�*»*«_ <br />SECTION I - Public Health Sorvices Environtnetital Health Division Tank Tracldng Sheet shall acconVwy eacb tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Heath Division <br />evl� s of acceptance of the tank by the disposal or recycling facility- The permit holder is responsible for mu;ing that <br />this form is completed and returned, Mret)5E IJl5Ti2 l i�ttr ptti <br />FACILITY NAME: <br />FACILITY ADDRESS: <br />TANK ID #39 - TANK SI;YE.a PREvI®Us TANK CONTENTS: <br />SECTION 2 - To be filled out by t��anok�t removal contractor: <br />Tank Removal Contractor: �itJ <br />-� City: Zip' ®— <br />Address: <br />Pyne #: 1 n t 3 i.. -- Date Tank Removed: <br />rt=*�*»=.»a=*#*�»»»w»**»**#*w»»***art#**»»»*®»»rt»**»»■www*»:,*rt=�»w*a**»»#*»»»*»»»�#�r»»»»+.w�+�a**rtwrt::»w»rt=*=» <br />SI'rCTION 3. To be filled out by contractor "decors ating tank": <br />Y Tank DecontmZ6191011 actor: <br />City: zip: <br />Address, <br />Phone #: (—)— <br />Authorized <br />, -. ) <br />Authorized representative of contractor certifying through slVature below that the tank has been decontaminated in an approved <br />ma=Cr as required by Cal EPA. <br />Nates: <br />Title- Si Date <br />*+r*a+rt*sre**+x»Saar«+aw»w�*rt###»�os�awartrt#*rtsx■r�m�r»**�e***wwwwa�**x�a�»*�rweert**.n»tw�M'mx��.*,xrt�*s�M�a#srw**#�wst�*aw*»*art**�r <br />SECTION 4, To be signed and dated by an authorized representative of the treattMent, storage, or disposal facility <br />accepting tank andior piping. <br />Facility N=e: <br />City. Zip: <br />Address: <br />Phone #:(�, <br />Hate Tank Received: <br />Name: <br />Title: 5igttatare• Date <br />»#*»»»»»»»*##»rtwwt,�.*»»x�**»w».**,�s»=»rt».*»rt#*».»»*:*»***rs»=»»**•****=wrt**rt»»»=.»»rt**�*#»:»»»»==»e»»..»__ <br />EH 23 046 (Revised 08113199) page 10 <br />