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s • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax- (209) 468••3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 form is <br /> completed and returned. <br /> FACILITY NAME: flr�� <br /> FACILITY ADDRESS: el(°��• ✓ �r (�fn Y`k� d/�i(' t �J 1�k' <br /> TANK ID#39- _TANIC SIZE: Jt0ic.(m,.( PREVIOUS TANK CONTENTS: 111 b'U e? <br /> i <br /> SECTION 2-To be filled out by tank removal contractor: <br /> ,' 1 t `' <br /> Tank Removal Contractor: y�a f 4Cy��A. LYL�S r'L'Y� 1I71 k ( �l i_t,'!t;_'I5; PSC <br /> -T <br /> Address: ;t , i LSCi�tflC,rl <br /> Alt", _City t! Gi(` Zip. <br /> Phone#: ( l- (l ) [)5 ('75C,- Date Tank Removed:_ LX <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: V_ It �t1VttGY1Vl1t'•ti�'rt' ��1ViCCS 4`1C <br /> Address: Z3 3 of r7 t _Pcs�laa to L -/(C' City: J`L' Zip: <br /> Phone#: y( E") ) ' <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 /> T 1 6 Date Zv —:Z - D$ <br /> Name:' � '�1Y1 �yYY',V1 Title: 'f YCSiCi�.i��5ignature: <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tank and/or piping1 <br /> Facility Name: tcc �A f_'.ts''A11)tiV <br /> V I <br /> Address: !Z�' -!` V t C f �.G_iC� City. !tlx 1 C(T'C. Zip: _ <br /> Phone#: •=( <br /> " <br /> Date Tank Received: Z� kvv� �"C tS� <br /> Name: �' Title: � tG � Signature, C . .Z Date <br /> EH 23 046 (Revised 12/31/07) 10 <br />