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SAN JOAQUIN COUNTYw EWALTH SELRVICES <br />ENVMONNUMAL EWALTH DIVISION <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br />Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br />ensuring that this form is completed and returned. <br />FACR= NAME: LbL211E 'JOr— 5t,\1\ -:S UN u \ N GyE LL l'� ES ' \U L Yf�R� <br />FACILITY ADDRESS:) $ 1 v S' �2 k LZ U 2.\ S l U L \< i o Z\ C L "—� S 2 v 5 <br />TANK ID #39 - / I I TANK SIZE: PREVIOUS TANK CONTENTS: �� 4, <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor:S l (� t Lia U t\� 5 �\v \ C �c S"C Ac l U N \ \ \ \� rt 41� /�1L\�1� I LC - <br />City: <br />C <br />City: S\'C� C\S LU 11 Zip: () <br />Phone #: ( ) 4 & 4 — 2 33 3,_ Date Tank Removed:__j \ Z <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor.C- <br />Address: ab a til OVk77 N L\, \\ 0 City: t\ 0 C 1" i U l\ Zip: g 5 G O 5 <br />Phone #: ( 22a <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: Title: Si 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:A, �. Q U a te\ ELM F= N1 <br />Address: 7 O () T01" \/,\ Z city: = uj�, L, o L- 'S Zip: '—L'k 5 7J 80 <br />r <br />I' � . r � , - 11► r <br />Date Tank Received' <br />Title' Si <br />EH 23 046 (Revised 9/11/96) Page 10 <br />