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IJ <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ar»r+s»ws»rrrrw»yxssrrrrsxrrrxrrr+rr»ssrrrrsrswr:rrwsr»s»xrrwsrrw:ssrwws+w»rrrrsrtrrrwrxwww»xxr»rrrtrrr»»ar»r <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 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 completed <br /> and returned. _ / / <br /> L <br /> FACILITY NAME:��L�C'7/t1� AnIZ/T 44- <br /> FACILITY ADDRESS: I;M• GOD/ <br /> TANK ID#39- 2R&ANK SIZE: SC7© PREVIOUS TANK CONTENTS: U�l/�i(J(acJ�tJ <br /> »+rrrr++rarwrww»rswssrr+«+«rsrsxww»twitrwwsrsrrsxs+rrsrr»xtrrtrrrwrra»rwrssw»s+wsws«rswrrrrrtrssrsrrrrsssssss <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: /J /Y)/ �i�,�Q�/Z����/� /".;C- <br /> Address:- (t7 / 7 F� C�Q/��f/�Ol(/' S /,• City: �Q / Zip: ��L 542y <br /> Phone#:( ZZ 9) _3 6� 61 7 s Date Tank Removed: <br /> »+*»rrrrrrrrr«rr+rrr+srrswrrsrtrrtrrtssrs»+rarrrrr+sw»swxrxwx»xwsssrs»»xxr*»»******************+*****+*+w+rrrs • <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: -- l n /h OAJoP�C— 401Z 11G . <br /> Address: C-2-77 E� City: G17V ( Zip: <br /> Phone#:( ) ?6 cf— 95J 7 5 } <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by/Cal <br /> �EPA. ? f <br /> Name:/ TMJ A07,12/-16 Title: Signature: Date 1> <br /> awx»s»rrarsrw»rarrr«rrr+rt«+«rrtr+«rrrtrtxrtrs«r«r«rxr»r»+xxr»rwrxwxrsrsrwrrrrr»rt««rrrrr»rrrrrrrrw»xx»srxrrsrrrr <br /> f <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. C C <br /> Facility Name:_ _SG �Lf �2 ,S !mss <br /> Address: D 0 tC �O�SGL7ly1 /3�(� City/?-` aQ ��Zip: <br /> Phone#:(t p <br /> Date Tank Recelived: �1 s: <br /> Name:�,-(� 460'lpA Title: I�.C/Y« Signature: Date Sp <br /> r++r:++rr««r+++rrr+wsswrsrr»xrr»»srswsrwrrr»rxw»rrxrr+rrsx+ssrs»x»rrr»rrrxrr»rrsrs»rrr»xaswwrxsrrrsrrrrar <br /> EH 23 046 (Revised 10/16/03) Page 10 <br />