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0 0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />cLvv5ED W PLACC <br />########################################################################################################### <br />SECTION 1— SIC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br />identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br />acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this finis completed <br />and returned. Im <br />FACILITY <br />FACILITY ADDRESS:C7� I I ul—�/ ain r v— <br />TANK ID #39 - T SO SIS D TANK SIZE:10� a���rt PREVIOUS TANK <br />SECTION 2 - To be filled out by tank removal contractor: �t <br />Tank Removal <br />Address: <br />Phone #: <br />Date Tank <br />City: <br />SECTION 3 - Tobe filled out by contractor "decontaminating tank": NA - <br />Tank <br />f 1Ar - <br />Tank Decontamination <br />City: <br />Phone #: <br />SU&4& <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 />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facili M� <br />accepting tank and/or piping. <br />Facility <br />City: Zip: <br />Phone #: <br />Date Tank <br />-Name: <br />EH 23 046 (Revised 3/15/02) Page 10 <br />