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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1-Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. I <br /> FACILITY NAME: 1)1'e,1�4 iG *9 �I FaG� `J% <br /> FACILITY ADDRESS: 1 Z K W. EL*\ s4(.c c4, 1-0A; , do, <br /> TANK 1D#39- TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SECTION 2-To be filled out by tank removal contractor: <br /> i f <br /> Tank Removal Contractor:_ k-k I tl�j X .Lt L)C1 _ > r <br /> Address:_ j L`() � -t✓t i�11g >L J�IT U-� City:: �c �f e� Zip: C� 5 y <br /> Phone#: Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: EC T <br /> II <br /> Address: Z 55- Parr Blvd. City: R-tC1 rV%0J Zip: 9f Liao t <br /> Phone#: ( Sl 0 ) 2,35S— 13q 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: Signature: 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: E CC <br /> Address: 25-5- J>c r r 13 City: zip: q so <br /> Phone#: ( 5!U ) 1Z7a57' 3 3 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 08/13/99) Page 10 <br />