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v <br />SAN JOAQUIN COUNTYHEALTH <br />ENVIRONMENTAL HEALDIVISION <br />r `• ► t • •� �, r, <br />ECTION I - 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. -gyp <br />kCILITY NAME: SU ��,UtK <br />ACILITY ADDRESS: n. main <br />ANK ID #39 - <br />TANK SIZEC3)8,0ao <br />ECTION 2 - To be filled out by tank removal contractor:ank Removal Contractor: LJ. t4l a"-.64 <br />PREVIOUS TANK CONTENTS: Cwt 5 <br />o <br />ddress: P® (p g City: c- Zip: 9S _3 9 / <br />:lone #: S — 23 7 g Date Tank Removed: <br />ECTION 3 - To be filled out by contractor "decontaminating tank": Q _ <br />ank Decontamination Contractor: V <br />ddress:�,t, "3 S J^ City: _ Zip: �EEa D S <br />lone #: (aD �i )� 33 / <br />uthorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />anner as required by Cal EPA. <br />ame: <br />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 />/1 l <br />ddress: '%D® iy- (,(� a.� U city: .t Zip: cf 538 <br />Zone #: (�2L2) % 60 8— 23 7 3 <br />ate Tank Received: <br />ame: <br />Title: <br />Signature: <br />H 23 046 (Revised 10/19/98) Page 10 <br />Date <br />