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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 dans 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:_ ? O/L r%A-% EN% FA.. T�fZ tS S <br />FACILITY ADDRESS: C? I G % O <br />!j'•Uuf.r Jj,c+an P,7 tJ.s/.:-E'/#Dr0 <br />TANK ID #39 - e e�TANK SIZE: 1j.1900 PREVIOUS TANK CONTENTS: /goc) 9Z <br />�**��am�•�K***x:*x�***rtrt�**m:�********rt**��**�*rte**n�***#* xx+*:�*�».x**�*xk*M:�:x**ro***�rt�*****x*rta*,*�rt�sk�.:ak*:�„�.� <br />SECTION 2 - To be (tiled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: "'°' �;`!: u6: i4''" r 7".• city: -SAW /__411,A),090 Zip: <br />Phone #: <br />61 ¢ - L29 Date Tank Removed: <br />{�•F4**� KKr+k***�e:k Me�lt.k****:x**+h i�:K#t��k k+k�M+k�6'k�A�*MSM***x��kie**�k**�K �K�****:kms***�M �N**M�k**�A:k�k**�h �*�a*�F** rye*Aa*Aa rt.:+k rt*a� �sfi*�*x:k <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Dccoatamination Contractor: <br />Address: Z 5.S f'�I/�R /34 yl�, City: /�S'I��1l9�•�U Zip: <br />Phone #: (_Ij O) 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: <br />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: <br />Address:_ �r�'Af city:. 1CNf9DNl� Zip: <br />Phone #: (, 242 ?- 3S <br />Date Tank Received: <br />Name: Title: <br />Signature: <br />Datc <br />4�+��K*$!a## #A�ke�pAe� # **� ** M sk.M+N�MN"k M'k.pe� # # * * *�-F iex *� ihs##:�#*�k#*�K�F �h# #:k �h•k #.IrdnM �k�M �kk+�k* �k:k �M W #�:k �k �k�#k' �M�M�Is� %M �: �+i� * *� �F# *� * M *� # b %a <br />EH 23 046 (Revised 08/13/99) <br />Page 10 <br />TI 39Vd cl001J HidIJ EEPE8906OZ L0:60 000Z/LZ/90 <br />