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SAN JOAQUIN COLTtTY PUBLIC HZALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />.wr.ww.w.r.w.r.Mb..wwyo vrw �r►w.•Nri.ww«,r..n.**.....s.w wti h w,kwwrrMr A«rwrrra+ewVwMwye*e.irrw ww aw w+e •r.w www.,w w.... mA A..A.* <br />SECTION I - 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 />-ithin 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this forin is completed and returned. <br />FACILITY NAME <br />FACILITY ADDRESS <br />0 <br />/S o®v o e� e� (1 eV �►'Fl)E® <br />TANK ID #39 TANK SIZE: ��/ �. � PREVIOUS TANK CONTENTS: fro e% cs <br />--�---�--- - VZ ijti LSA ib <br />cu <br />..w...xeA..M.M :h #h rw MMe �1 M *+M 4'ibw.xeww Wrpw ye.wxe.w,i.....e�.#wwwk��WMeww,K*N+wgfuewM+eavww..w:. zewxeww.a+.rw.wwsew+www.nww;,rw wwV.wwww,:w�f w.:a <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: 2-(1oc �<(%/�/�, L� S //,�,. <br />�� City: J!%-' h�s4.�Q/df� ZiP:�Z/. f <br />Phone !i: (/O ) Date Tank Removed: <br />...+w#wAawwwwwwM+wwwr+(.rMww,�,wM++r�u ryew rawww�ea#sewraMwwrte�r�Y#*ye kt rt�Ae aemwp,:a■www�uwwk�ww:wro##,diarwrwrMe q,ww�eowaw.wwwwx+'Mre ye heryeww•w:.5e <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: (,X49 <br />Address: eL t 5-7 - ' City: i�ZJAJ b Zip: <br />Phone #: ( 40- �j �y �'' 0 -76 <br />Authorized representative of contractor"ccrtifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: <br />Title:Signature: Date <br />w w iN w riu,ukrxree ye+{e,aaeaMw+u ww,envx` w �u#wap r dew# ###ode#Wdeslt�le %t yo Me * wt# �N,sw�M�MM�1r�IeaM+R M w+a.ua+�kxnFr##�#aM### �kke t� ptlk pe pt Mt lvwww w,r� �h w+Mr+h �+et+M+Y*i1e�4t�dey, �M w R[ ye � 4 re <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: L 617-. <br />Address: Z SS ,�i9,en / Vb City: 9OC tv ) j) Zip: ?Ygo/ <br />Phone #: )-2-32' /„3 / 3 <br />Date Tank Received: <br />Name <br />Title: Signature: <br />Date <br />rr�.w w.ax.a.,.wH.+eewm#�awaaw#.1e##ww+N+it�k�k�k�#t+kke At ya#y,Mye*yoswaarksMawwr�a+w�luMMew#w�1e#,1eAe,MMM#�h�N�1e�6esnNie**�*OMks+h+Rwwyna+v�+rw w+M****4+K4***Rr ke ke <br />EH 23 046 (Revised 08/13/99) Page 10 <br />