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*4.. <br />SAN JOAQUIN COUNTY <br />Tedephane: (209) 46$-3420 1Fnx: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />D <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 H a t Hor4 � k F-- t I- C - <br />FACILITY ADDRESS:`• <br />TANCID#39- 1 I TANK SIZE: =ft f.4=l,ILC_PREVIOUSTANKCONCENTS: 1 iohi,, <br />_ <br />SECTION 2 - To be filled out by tank removal contractor: <br />b C <br />Tank Removal Contractor: i` V a ;0.-i e1"t C_S\\11 <br />Address: j( <br />City: _!-G_ i! Zip: <br />Phone #: (��`,-1) % _.i•7 . �r� <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: :'l.'+la �YY`.4� _Title: Y �', '1 ,ns1 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 />L� <br />q k l <br />FacilityName: ,\j �'S-{' � (>.�-1' C—^x,J. iii( h ---- — <br />Address- iZ� 1 � utCa V �°u _ _City_Zip: <br />Phone #: C. �=�_` ') (: t,L-- <br />Date Tank Received! /0— L <br />%, ,•I' ,t itle. i 9ignaturel .6647 <br />####'k##i8##"##*.###:k####dk###BY k##? kk.#####t#d k8k###kkk###k#5i•t8t'k.kd:##—'k'kkY:9#####>##k-%1+#+. d:k.k#*#t#R:k'k 4:Y fi-# <br />EH 23 046 (Revised 12/31/07) to <br />Date Tank Removed: <br />SECTION 3 - To be <br />filled out by contractor <br />"decontaminating tank": <br />1 t <br />Tank Decontamination <br />Contractor: G1iit1.111' <br />L..: <br />Address: 3 7 , <br />_City:_ <br />itL�, 4 .. P <br />Phone #: (��`,-1) % _.i•7 . �r� <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: :'l.'+la �YY`.4� _Title: Y �', '1 ,ns1 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 />L� <br />q k l <br />FacilityName: ,\j �'S-{' � (>.�-1' C—^x,J. iii( h ---- — <br />Address- iZ� 1 � utCa V �°u _ _City_Zip: <br />Phone #: C. �=�_` ') (: t,L-- <br />Date Tank Received! /0— L <br />%, ,•I' ,t itle. i 9ignaturel .6647 <br />####'k##i8##"##*.###:k####dk###BY k##? kk.#####t#d k8k###kkk###k#5i•t8t'k.kd:##—'k'kkY:9#####>##k-%1+#+. d:k.k#*#t#R:k'k 4:Y fi-# <br />EH 23 046 (Revised 12/31/07) to <br />