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11/02/2001 10:47 9166813.L31 <br />CN�[�l7al►f�i�[ <br />L-1 <br />SAN JOA.QUIN COUNTY PUBLIC IIEALTIi SERVICES <br />lENvIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACYJNG RECORD <br />PAGE 13 <br />SECTION i - 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 Enviror=ental Health Division <br />vdt of acceptance of the tank by the disposal or recyclizzg facility. The Permit bolder is responsible for ensuring that <br />this form is completed and returned. �� ���'} 5 tt�i 1 ` 01, -POT , <br />a <br />FACU ITY NAME: <br />FACILITY ADDRESS:—90 t) -r�4 � ,O h I — <br />TANK ID #39 - TAMC SIZE: <br />Q PREv1OUs TANK CONTENTS: l,i — <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: 6EOE j _mac <br />Address' City: t�Cli� � Zip: <br />Phone #_ ( +� f.r �7Date Tank Removed' <br />SECTION 3 - To be filled out by contractor "decontaxaWating tank" - <br />Tank Decontamination Contractor: <br />Address: <br />M <br />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 />Nance: <br />Title: <br />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 />Address:_ <br />Phone #: (^-)– <br />Date Tank Received: <br />Naive: __ <br />Title: <br />City: <br />Zip: <br />Signature! Date. <br />EH 23 046 (Revised 08/13/94) Page 10 <br />