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`W <br />..001 <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 4163-3420 Fax: (209) 463-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*****tzztt:t:x*astttt******at*ttatt*t****t*ttt*tttt**t*t***tt********s*tttttstttttt**zzt*ttttt***tt*******s* <br />SECTION 1 — SJC 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 retained 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: G H ', H&r+,qckq t L_ L <br />FACILITY <br />FG 5c, <br />TANKID#39- � �(;1„+j,5 TANK SIZE: (XCC' ,(1,( PREVIOUSTANK <br />i <br />or Cj 37[- <br />*tttt**tstttss**sts*sttst*tstts*s**tttzzttt:ttttts**ttttttzzz*tttttttt*t*t*ttttz*«*ttt*:ttttttttttttztttttt <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal <br />ti 4 <br />StV yr�L'S1lriP�l'u C )(1, 'd v es; it nE . <br />City: t t t(.e y Zip: 1 J3(:ti <br />r - 1 <br />Phone #:( -t- (ZDate Tank Removed: /b 4-06 <br />N <br />t***t****ttttt*tt******t*t*ttttttz*s**t*tt***t*t*tt****t*ts***t*ttt*tttst*t*******ttzzz**tt*z*t*ttttt*tttzz <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address:Z:5t' �ICtC(tiDJ./YC. City: iY�li\6 Zip: <br />Phone #: (� �)) C 3.3 ' C 715 L' <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as rjequired by Cal EPA. T') <br />Name: <-A� {"'4 :I �1j Y`j .4� Tid i Y SSS i i :A A Signah:re: Date �V �2 - DA <br />**ttsts**s**t*ttt**tttt*t**ttt*zzzt*t*t*t*ttt****tttttt**z**ttsx* z**ttzt*stttt*tzt*s*s*tt*tts#st**stttss* <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 />O (A- - <br />Phone #: ( ( <br />City: ! oui ( SLC k- Zip: <br />-------------.-_..- <br />EH 23 046 (Revised 12/31/07) 10 <br />