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SAN JOAQUIN COUNTY PUBLIC HEALTH <br />ENVIRONMENTAL r HEALTH ` DIVISION <br />1 110 <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 ADDRESS: e9vo 0 <br />TANK ID #39 - <br />TANK SIZE: 000 PREVIOUS TANK CONTENTS:Tu41, e <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Lr. ler oys r g Ac 7�/ S r'✓ ®'e° e s <br />Address: 060 ` AoenVree r,�we 06 City: C.4ieo Zip: 99f 7.3 <br />Phone #: ( 6 3 0) 34/.57- 9,56 A Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: r1,4!,IL e54airgnme'n c` S' rve'rrr <br />Address: 59,R 0 C�.n ere/,9 /�l ve `� City: •/Lie. ® Zip: .5-,37 <br />If <br />Phone #: ( i2®!2) 91-7 0 77s <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: <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: Wr, r . <br />Address: 9.79 ,9 sof'-f-4 yy- RoAd City: H4,n lee -a Zip: 915-J3 6 <br />Phone #: (o"z r Y46 -?W—,;1• -off. 0 1) I a -Sri &c,1,,& Ce. -Ac <br />Date Tank Received: <br />Name: <br />Title: <br />Signature: Date <br />EH 23 046 (Revised 9/11/96) Page 10 <br />