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SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING 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:_ M pI(H o4_9 C'� C. L <br /> Lid <br /> FACILITY ADDRESS: ) J-lL yrii1"JdM kit <br /> lP tA1C 73 t <br /> TAM{ID#39- P `�O,4� TAM{SIZE: I r�[J ' i ' r PREVIOUS TAM{CONTENTS: f 6!Ln)LCi1 <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: ytl MY C Y1S11Y7t �l jCJ b`iCfS, 1Y1(' <br /> Address: ptsoLLdf-rC {Vf, City: Zip: <br /> Phone#:(l�'�t ) r"» �' 7'-J ` Date Tank Removed: /D>6 <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> /� n <br /> Tank Decontamination Contractor: (Vi t��'t� Z.-Y1VefC•YlY}DE(1'�'tt� ,,Ll'ViC;t=3. o1C . <br /> Address: 2;37.5 f. Y'< f�l�fr City: iti' tCZip: �.J,`.3�� <br /> Phone#:( /['9 3 Ct 45 <br /> Authorized representative of contractor certifying through signature below that the- c has been decontaminated in an approved <br /> manner as required by Cal EPA. r` <br /> Name�V�D ��01��b1 Title: }'lC.SldtSignature��41 Date <br /> SECTION 4-To be signed and dated by an authorized representative of the trey ent,storage,or disposal facility <br /> accepting tank and/or piping. <br /> y <br /> Facility Name: te�iC�>} C`� CtSt tc-z <br /> _ rn a <br /> Address: 1!71 C1 ilcrl City: Tiulc Zip: <br /> Phone#: ,.?C'cl <br /> Date Tank Received: r'� � <br /> GI <br /> Name: L Title: Signature: - Date Q 1 <br /> r <br /> EH 23 046 (Revised 12/31/07) 10 <br />