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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> raraasrraaas►rrrrtssr+srrr*rt**+rtrtw►ssrts+***awrtwwss:s►srs+s++rs*rtrtwwss+s+*s*wst+s+****wss►ss►s++s*r►*wrrtrt*r <br /> SECTION I—S!C 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 /> FACILITY NAME:_��/�`� /°J/' <br /> FACILITY ADDRESS: / '02/I/� ) O ��{ D R A G� d E: 4 )P <br /> TANK ID#39- TANK SIZE: -5-0 (),,PREVIOUS TANK CONTENTS: 4JN XWO W ti/ <br /> ►s++*rtrsrssarrrrrraaaawswrrwarsar*wrtwws►sats**w*rtw+wtwrs►r►+r++►*+rt*rtww►++swrtrtssss+srrrtwrrtwwsstrswrwwwrr ' <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: City: Zip: <br /> Phone#: Date Tank Removed: <br /> *wrra+s►+aaraw►assr++rrrrssrw+rtrtawrwrsr+rssr+•*+++s+•+rt*+s*+*++s*+***w*wwss+saws*rtwrtrwwwsr►srsss+as*a+++ <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone#: <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: Title: Signature: Date <br /> rtwwww►www+sr»*rtrt:**rtrt***rt*sws*swrt*rtwwwwwwwrtws►s►►►►►swr►►rssw►w+++►s+►**+*+*ttww►t►►rts+rtrt:++*rtrt*+rtrwwww <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 /> Facility Name: <br /> Address: City: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ■+r►avers►a+a_+►►►ave+rrs++++r+s+r+++►++++++++►+s+ss+►+a*+++*++++++w+++++*rtwsras++++►*r**wwssr+r►rrr+a►+rtrt <br /> EH 23 046 (Revised 10/16/03) Page 10 <br />