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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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 completed <br /> and returned. / <br /> FACILITY NAME: l lru!1 17 <br /> FACILITY ADDRESS: ��� <br /> TANK ID#39—TANK SIZE: J 66 A L pREVIOUS TANK CONTENTS: 6A-CA <br /> v <br /> i**i44ii}ii#444}ii44rt4fii*r;\4#i#*\#kk**#i};###i#irt#}ii**rt4rt»#**rtrt44i*i\rt#rt4##4i*irt4rt#i*i*r4+*4ii*rt#4i»#*rt4 <br /> SECTION 2-To he filled out <br /> �by/tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: 21, City:_[A�I12(,040Zip: <br /> Phone#: S( �d ) �, —� �Z O Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor:T <br /> Address: / City: Zip: <br /> Phone#: <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: Signature: Date <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, storage,or disposal facility <br /> accepting tank <br /> and/or piping. <br /> Facility Name: <br /> Address: J S �7��i� �L)l�/7 City:l���� Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 3/15/02) Page 10 <br />