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' SANOAQUIN COUNTY PUBLIC HEALTH SE CES <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. ' <br />�CFE�1SE- D/tl-2//3Urion� UG -.SOT'' <br />FACILITY NAME: �1/i.i-��:<F 4O6L/sl/0__3 f 6C -1'e / .Yif1V SU(24f//y if/thePF Pe -007 - <br />FACILITY ADDRESS: >0 Q c. i2 Q T y /Z/_)1 <br />TANK ID #39 - TANK SIZE: ✓;2,,Q161PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: -77:-/V (I _ , <br />Address: <:67S— C�) U//\/ rlq C2 7- S'rc:. L7 City: .S-,qe C/j/rfCIV7-6 Zip: <br />Phone #: (q/� ) 16- rl -� b ,% Date Tank Removed: <br />SECTION 3- To be filled out by contractor "decontaminating tank": <br />0 ank Decontamination Contractor: <br />Address: City: <br />Phone #: ( ) <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 />Name: <br />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 #: ( ) <br />Date Tank Received: <br />Name: Title: <br />City: <br />Signature: <br />23 046 (Revised 08/13/99) Page 10 <br />Zip: <br />Date <br />