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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 pax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 30daYs 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: ' rV a4_9 <br />FACILITY <br />e, c_Lc., <br />�Girq, 81737v <br />t <br />TANK ID #39 - TANK sizE:��CPRl EVIOUS TANK CONTENTS: 1 �11RIlb�i i1 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: 1U%i(ii l ewi cl ywof'nh[, <br />Address: City: 7 r`r" Vt. Ci !(�CIJ Zip: <br />�� <br />Phone #:( Z -r 1� �' > > ' L 7 17 C� Date Tank Removed: %0'6- G 4f - <br />SECTION 3 - To be filled out by contractor "decontaminating tank": j <br />11 � � Cjy � C <br />Tank Decontamination Contractor: `!� 1 [ �� i"Ci C-t1� t k C n I I if f l'h(( -Cs i 0C <br />VC. <br />Phone #: ( ICel ) ' 7 3 ' C) 75 <br />L: <br />City: 11 aq Zip: 1 <br />Authorized representative of contractor certifying through signature below that the <br />manner as required by Cal EPA. <br />1) <br />T1CS(I <br />SECTION 4 - To be signed and dated by an authorized representative of the <br />accepting tank and/or piping. <br />Facility <br />Ltsi <br />has been decontaminated in anapproved <br />storage, or disposal facility <br />Address: �7 1 1, �C °1 i1f�r Tc -ad City: i l G ( Zip: <br />Phone #: ( Ct Cf f t <br />Date Tank <br />Im <br />o- <br />#######*#### <br />FH 23 046 (Revised 12/31/07) 10 <br />