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SAN AQUIN 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 />p�/=GNSG �7iSTa2/,r3UT'iON ,[��-/o0i <br />FACILITY NAME:T- <br />FACILITY ADDRESS: 117100 C p 71// <br />TANK ID #39 - j/j /S/p�1�,3 TANK SIZE: ���p O��Q PREVIOUS TANK CONTENTS:y.)E-SF1 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: t) FN G %xf C - <br />Address: S- (40>Al2-1t C' -Ti STE, l7 Zip: <br />Phone #: ( /G ) 6S- / - J ZO ) 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 />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 />EH 23 046 (Revised 08/13/99) Page 10 <br />Zip: <br />Date <br />C <br />1] <br />