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':'��� ��:����►1F/��.\ �_�� ���a ���,� �� �a �'' �� � iia � i <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />########################################################################################################### <br />SECTION I - 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: G A t^ Hor+ aq e L,. L <br />FACILITY <br />0537L, <br />TANK ID#39 - ii;lnf TANK SIZE: �r� (PREVIOUS TANK CONTENTS: (ilk�(Gbi) 0 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: Z 3`1,r <br />Phone#: (Zt Ll) [ �J' �' 7�� Date Tank <br />SE€"ilOPi 3 - To ba irPhdoatbp eeatraeter ..�5 tank": <br />Tank Decontamination <br />&v1t <br />Ylc . <br />City: --5- tt I Zip. t... <br />�3C t1 <br />Address: �7 c 1Scaci t f C -- `I C . City: i <br />Phone #: (/ <br />Ct 53t- 4 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as raequired by Cal EPA. <br />Name:YS11 ,91 � 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:' ' 4 L.c't" <br />Address: Z2 <br />Phone #: i( <br />Date Tank <br />�r- <br />City: iCO t(A k-_ Zip: <br />Title: Signature: <br />######################################################################################################### <br />EH 23 046 (Revised 12/31/07) 10 <br />