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r.. <br />..f <br />SAN JOAQUIN (COUNTY <br />Telephone: (209) 468-3420 Fax: (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 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. E <br />FACILITY NAME: f' �� c, MD43,3cj C: L- L L <br />FACILITY <br />TANK ID #39 - °i4 TANK SIZE: P r �'�'r (• PREVIOUS TANK CONTENTS: CIA <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: kX� h t M rt _ ni) ii -r . S`)iw n Gl l `)Ct G <br />Address: t ��Ir"J <br />C. Y��TttiLsi, <br />/1yP <br />City: IIGLC_p�Zip: qJ3r-li <br />Phone #: ZL 41 <br />7'5 E> <br />Date Tank Removed: <br />%!!(.� <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: s�'! -P{l�u <br />Phone #: <br />0 VAC C3. Inc <br />City:_ kwatj Zip: <br />Authorized representative of contractor certifying through signature below that the <br />manner as required by Cal EPA. <br />D <br />do <br />SECTION 4 - To be signed and dated by an authorized representative of the <br />accepting tank and/or piping. <br />FacilityName: <br />Address: i4%ZI Cr9ilt` <br />Phone#:( Zeci L�IGf tl: <br />has been decontaminated in an approved <br />Date Ic <br />############################### <br />storage, or disposal facility <br />City: Zip: <br />EH 23 046 (Revised 12/31/07) 10 <br />