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SAN JOAQUIN COUNTY PUBLIC HEALTH <br />ENVIRONMENTAL 1 II DIVISION <br />*********************************************************************************************************** <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: c+jkk <br />FACILITY ADDRESS: 01 r::--eTZ"Li= <br />TANK ID #39 - TANK SIZE: '� e.-e_Pl-. PREVIOUS TANK CONTENTS: o` t--• <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: `\XWT 66V45-RAOft M <br />Address: P f9• ttoeJ City: �-•enc;> t Zip: <br />Phone #: (205� ) % 1��O Date Tank Removed: 6'�J+ • l 3 • c'g - ry <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: � rGc City P4- +� Aml7 Zip: � 1 <br />Phone #: ( 61 C) ) --2 • ( t `j 3 <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: <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: 2 V�;,5 City:R�i� <br />Phone #: (VJ i !)) <br />Date Tank Received: - <br />Name: - Title: <br />Signature: <br />EH 23 046 (Revised 9/11/96) Page 10 <br />Date <br />