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RISCRYsD <br />ENVIRONMENTAL HEALTH DEPA` IF-ALT�-t <br />t t <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE T`#ANK DISPOSITION #TRAC#TONG RECORD <br />SECTION I - 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 form is <br />completed and returned. <br />FACILITY NAME: /7 O Q PN <br />s <br />� amu <br />FACILITY ADDRESS: Q /� <br />- <br />TANK ID#39 ->� u yc-y y TANKSIZE: PREVIOUS TANK CO <br />Ys -4s NTENTS: <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor:_ - ,� l <br />Q e t, t <br />/t� r a -r- JCC a, ,. a n <br />Address- �6 f%T <br />e NW(�r a city: �esJT1 /1 zip: <br />Phone #: <br />( Q C/) ,�� / Daze Tank Removed: ,0 �� llj9 <br />c� O / <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />ri <br />Tank Decontamination Contractor:�1,L�» <br />rr // � Cx n ctu eaT o cs /L <br />Address:_ Z4 T e e4 s� 7� Ci I <br />v <br />Phone #: <br />Authorized representative of contractor certifying through signature below that the^k)ft been contaminated in an approved <br />manner as required by Cal EPA. <br />-07 <br />SECTION 4 - To be signed and dated by an authorized representative of the tr i###rt###srtfrt#s#s#s#ii!##i##i <br />accepting tank and/orpiping. eatment, storage, or disposal facility <br />,+ / <br />Facility Name: / D� Cit (_ ,-,� E- a _l <br />Phone #: <br />Date Tank <br />EH 23 046 (Revised 07/31/09) <br />1� <br />City: /i r[o n,<-Zip:g 3 <br />wt a Lcc� Signature:_�K/� G1 /liJ te // /2 <br />10 <br />