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SAN JOAQUIN COUNTYHEALTH <br />ENVIRONMENTAL HEALTH DIV• <br />11 <br />ECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />ithin 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />is form is completed and returned. ,� <br />ACILITY NAME: SU CK 1 I Vf A-P_�cE I <br />ACILITY ADDRESS: ?.I o n. I ' lQ i <br />ANK ID #39 - TANK SIZE(3)S,DaO PREVIOUS TANK CONTENTS: Cwt 5 <br />ECTION 2 - To be filled out by tank removal contractor: <br />ank Removal Contractor: LA) a4 & . , Z) . <br />D <br />ddress: pCity: Zip: JAS _� I <br />none /1: (a2 ® } 4k Fa 93 7 g Date Tank Removed: <br />ECTION 3 - To be filled out by contractor "decontaminating tank": <br />ank Decontamination Contractor: E&A ( V �. <br />.ddress:�,S"3 W i�Jit City: 2.-Y.. Zip: CJ�o2 O S <br />hone #: (ao �) y-� — 33 7 <br />•.uthorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />canner as required by Cal EPA. <br />+ame: Title: <br />Signature: <br />Date <br />ECTION 4 - To be signed and dated by an authorized representative of the treatment. storage, or disposal facility <br />accepting tank and/or piping. <br />'acility Name: <br />ddress: 700 lel - U) av"& City: Zip: 5.S3V <br />'hone I#: ( ) , (0 8 ` 9 3 7 3 <br />)ate Tank Received: <br />lame: Title: Signature: Date <br />:H 23 046 (Revised 10/19/98) Page 10 <br />