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SAN JOAQ UIN 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. <br />FACILITY NAME: eyi4 c zwrrg 1''!us es <br />FACILITY ADDRESS: 900 ✓/G % 1? SO, Z0121 <br />a is, 000;1 i v ut AVA DCO <br />TANK ID #39 - l F TANK SIZE: IS, c, ca 0 PREVIOUS TANK CONTENTS: 9 ^ I -C9 0 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: P/�/j{f P SCa <br />Address: 2600 ld&/- Z-4171 ST city:,SM 1 ® D1?0 Zip: . S- 77 <br />Phone #: 1 3 9 0 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: 5C/ <br />Address: 2—SS PjZlZ L MO.City: %{/C� c� ,� Zip: 0j <br />Phone #: ( 370 Z - 13 9 - <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: <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: EC j - <br />Address: 2 574- IPAjZ9 S L 1/0 City: R 1411,41 p Zip: j <br />Phone #: (S-1 0 ) ?-3 ' % 3 3 <br />Date Tank Received: <br />Name: Title: Signature: <br />EH 23 046 (Revised 08/13/99) Page 10 <br />Date <br />