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SAN JGtUIN COUNTY PUBLIC HEALTH SERAS <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 />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: <br />FACILITY ADDRESS: <br />TANK ID #39 - TANK SIZE: % Z PREVIOUS TANK CONTENTS:%Z,4t&+iri <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: `< ' , < c:\� c .�C ` _ C, 7 <br />Address: �C' � ml- W ;:� tb City:v�7t c- ,ti Zip: <br />Phone #: (2Gf ) G l.( Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: C: , _ (,IFOCeA) c <br />Phone #: (tl ) 421 �- <br />Zip. e -;7T ZG, <br />Authorized reptesentative 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 />FacilityName: <br />Address. �.City: zip: <br />l� <br />Phone #: <br />Date Tank Received: <br />Name <br />Title: <br />Signature: <br />EH 23 046 (Revised 10/19/98) Page 10 <br />Date <br />