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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. <br />FACILITY NAME: IJ.I4 oA) ErEA x/2 / ,5 .5 <br />FACILITY ADDRESS: B80 VICTOR RQ ZQR1 <br />TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: kJ4,S rC 014 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: EARd P I S O ,&'C .4/lJ/G 1AAC, <br />Address: ;?600 W11 -4J ST City: SAA.J 4RA41DROZip: 77 <br />Phone #: ( I6%) 1 9O Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: 4rc 1 <br />Address: /Q L City: /CA.,P Zip: <br />Phone #: ( /O ) 2 - /3 9 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: <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.7 <br />Address: rJ M/3 R 8 4.V City: /CifJ� !� Zip:.9 Ifleez <br />Phone #: ( /D) - /3 3 <br />Date Tank Received: <br />Name: Title: Signature: <br />EH 23 046 (Revised 08/13/99) Page 10 <br />Date <br />