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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 retained. <br />FACILITY NAME:_ C.,; H A G M D4q ari t✓, (-L <br />FACILITY ADDRESS: <br />T-610 9537L - <br />TANK ID #39 -1 -N Iji4 h TANK SIZE: l i 0f - PREVIOUS TANK CONTENTS: UnL lw i i <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal <br />I ,- <br />Address: Z SCI 7 e pCSC0.�f GAVe. City: Zip: <br />Phone #: ,c( Z't t ) L LJ C> Date Tank Removed: _ <br />SECI'M 3- To he fi&d out by caatractor "decoatamirtatirtg leek <br />Tank Decontamination <br />2.'ft <br />Phone #: ( /C'9 ) E)--53' Cy -15 8' <br />C -f-3: Inc <br />City: Iyaq Zip: C6,5&q <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'V''117 4)n Title: TrC t4 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 <br />S+ C( MA < <br />Address: )Zz! �, 1C�TIC"F-LIt-1 City: LV)GU- Zip: <br />Phone #: (Z ccl) &6[ ti -39e <br />Date Tank Received: <br />*s****sss**sss**ws********sss*sss******sss**sss*ss*ss**::ssssss*s**sssss**sss*sssss*s*ssssss****:::ssssss <br />EH 23 046 (Revised 12/31/07) 10 <br />