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NIT .ONl �EN'?'AT AT Tu ` . p wWETv ..� <br /> SAN JOAQUIN COUNT 0 20`16 <br /> Telephone: (209) 468-3420 Fax: (209) 4MjJ43:�`"t r nJ <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 pen-nit holder is responsible for ensuring that this form is completed <br /> and returned. <br /> FACILITY NAME: //�OIk�p���dL���J/r'� (��it� O'/1���� t��/��D✓����j <br /> FACILITY ADDRESS: l tJ �� `t/, S / �� �� �� ZDl�l <//e' <br /> TANK ID#39- G TANK SIZE: S� PREVIOUS TANK CONTENTS: <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: - i�o/�P� �/� raG�• - - -- - -- -- - <br /> � 52 / <br /> Address: �� ,`� S- <br /> >� � /� City: Com/✓ � Zip: 2/ <br /> Phone#: `�' ' v, �`� �✓� .-Date Tank Removed: — — 2 <br /> SECTION 3-To be filled out by contractor"decontaminating tank": / <br /> Tank Decontamination Contractor: 'c /may/ //T��/'� O/G r�G/- <br /> Address:��0 -3 5- 2 City: Z-,0/✓n <br /> J Zip: �L / <br /> Phone#: 3 j6 C9--617-5, <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 /> Name:& // Title:ri2Jfe41-7!!j Signature: Date <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. / /� <br /> Facility Name: ��7�l 5 7f�( ��©j /c <br /> �2 © t� 7� /��� y� �2r �S 7 f 2 <br /> Address: D r ��� Cit �� 7r//� Zip: <br /> Phone#: � [ dS,)` <br /> Date Tank Received: 2`�� <br /> NameICZ �) he Title: Signature. Date <br />