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RECEWTRRONMENTAL HEALTH Df#X*FME fi§' <br /> MAY 0 5 2016 SAN JOAQUIN COUNTY',"topt-_ - MAR I 2u <br /> ENVIRONMENTAL HEALTH Telephone: (209) 468-3420 Fax: (209)'468-3433 a � y ,` <br /> PERMIT/SERVICES z <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD' <br /> SECTION 1 - SJC 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 completed <br /> and returned. j� n <br /> FACILITY NAME: / /ZUP� � 4,, `/ <br /> L F�4e-7I ed&1( IV4a <br /> FACILITY ADDRESS: �3 ���� ��� 5Z 140 <br /> TANK ID#39- 5�5TANK SIZE: 40 PREVIOUS TANK CONTENTS: !14)t/ ,�7Q:F�/ �SD� - <br /> * 1 <br /> SECTION 2-To be filled out by tank removal contractor: ^ <br /> Tank Removal Contractor: :5 2/lY/ 0_&g 014L /��• / <br /> Address: P-0 ©X 3 52 City: Zip: <br /> Phone#: ( 20 36� 75 Date Tank Removed: ��=/ 2-6�1% <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: J 1 1-�v 691Z A C, <br /> Address: ?© L,2>e-_ _ 7 City: Z e�)'/✓) /—Zip: �25,z <br /> f <br /> Phone#: (� 7) /J — �2 / <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required <br /> _b'yJ Cal EPA. /�� y� !� <br /> Name:' �r4T`v//7���1'k'Title:L r/�/��c Signature: f Date l r <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. s <br /> Facility Nam/e: ,�<i�V�/ /—��/� � �/tG 4 � <br /> Address: / QQ ���L.�1 � /�/� City: ��21�r0� Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Title( VN1Cel'Y"' . ✓mature: l)�13 Date <br /> EH 23 046 (Revised 07/22/10) 9 <br />