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SAN jOAQUIN COUNTYHEALTH <br />ENVERONM:ENTAL HEALTH DIVISION <br />UNDERGROUND STORAGETANK DISPOSITION,3r • <br />RD <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: FLAM t L ! ,uC3�s t tJG - <br />FACILITY ADDRESS:_1 -2— <br />TANK ID #39 - Fi-- 3 TANK SIZE: 10, UQ O PREVIOUS TANK CONTENTS: U,OiC C`�.a �D GAS <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: I1�:t-�Q�%�� <br />Address: Q`= ?� i •? City: LJV C. Zip: <br />Phone #: ( t c) 3 7 23 _11 1 rc=a) Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: A L-ro"i <br />Address: 1' J i� ?`- i D Z S city: W • Zip: ''I � 6 <br />Phone #: k ) 3 -13 - i i rates <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: 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: WE$T GSA $rule; i <br />Address: j 1N. L.IN WOLF® Ciry:TL0CK- Zip: 953 <br />Phone #: ( ) (2 lb C <br />Date Tank Received: <br />Name: Title: Signature: <br />Date <br />;e:rtartrtrtartrtrtmrt�k aY p�*rt+Rartart rtaartrtakrtsrtrtrtrtrtrtart+artrtrtaaart�saa�•us.�s+s:e++m•u+Mr�k%�.us,sa,awx.r�M s.rrr....a.Me,r,u+Fart�.sa,e,M u.,oer ru�r.,krw�P rte�r,a <br />EH 23 046 (Revised 7/10/96) Page 10 <br />