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SAN JOAQUIN COUNTY HEALTH SERVICES <br />UNDERGROUNDENVIRONmEWLAL HEALTH DIVISION <br />STORAGE,O,*N TRACKING RECORD <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 />FACILITY NAME: -FC*,,, VO 3- t <br />FACILITY ADDRESS: I'=6 i� K= i_G:WA10 LAS � �$�` � G lac. <br />TANK ID #39 - 2 TANK SIZE: 0 0PREVIOUS TANK CONTENTS: U,NLC` ��=b GAS <br />��(-LO&i <br />SECTION 2 - To be fulled out by tank removal contractor: <br />Tank Removal Contractor: lit 4LTo") E:-PjG"° ! nJ "`lam ` <br />Address: <br />Phone #: ( Iq t c7 3 7 5 —; i k7 P4.5 Date Tank Removed: <br />City: iN. .1 t4 C. zip:_`�5 � f <br />#� Mak a sal[aMa.k �Ic+k ck *ckacae*ek * aae a saeaasaae+k ekskakaek****ycek ye�ka ekae�k*aR*�***ek �kaa��K�K1k*k�es�k �K***yc�es%**a * aeae ac aeaess ek* *ac*ac�Icac*ieaye * ac**Hc Mic aesaa;ea:.e <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: I'MA CrotjC- <br />Address: 1' J :, ?`°- I D ZG' City: W. Zip: w? ° 6= q-1 <br />Phone #: ( yi 1 (v ) 3 -13 — i ; e9�5 <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: 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: 'VjS'T CDA S7 FUS,) (Fi IE-X1`r <br />Address: 151-0 0. L,.l N t OOD City: TJ4 L c7 CK• Zip: 9 S 3B O <br />Phone #: () ���v C 2 <br />Date Tank Received: <br />Name <br />Title: Signature: <br />Date <br />saaaas*aaaasaaaaaeaaeaaaaaa:sa*s•saassaasa saaassac+saw*.ka.a.Aae+Ra�M+ee+kr*aaees.rrw�a es a�sws as a�eet�u+k�M �e+rr�aot r�aa��srr+M+k+k rfs �a �k air <br />EH 23 046 (Revised 7/10/96) Page 10 <br />