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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> wwwrtrtss►s+trsrtssit*rtsssr**►►►iww**ii►+si»►iw***i*►iw►s+r+*#w*wss+***ii►►ss#w*t►►iw++*rsws+**wwir►+ii*w*►is+ <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 /> FACILITY NAME:r[7 <br /> FACILITY ADDRESS: '1 D6 X14 a) (0 E / )S' L��'OC <br /> TANK ID#39- TANK SIZE:__Z —O OebPREVIOUS TANK CONTENTS: e, A/XNo W 1�/ <br /> rt►rswrrrt•srlasisrwrtririrt►+rsii»rt►►srrirwiwwrtsissisirtrt*s►s•►++*ti►s►+tiw*wY►»s**t►►ass#*rt+►►►*i++rtrtss►ts+ <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 /> i#►t*##►i+t+r►#4►iiw##*+ti+*#4iirir+*##YYiii+i#w#*►ir►+#4+rt+►+►►#*irtrtrtYi!!*+►+►i►irrt►+t+►#t►►►►ii4rttrt►tts!* <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 /> *rti►sr►witrt►iras**irt*►»is►+#*rti►►i+*iw*rtrt►►iit+i**4*t**iiii#►*iw*Y►iis+►***►t++wwr►+►twrtpsgrrtrtrt#+iiirrtrtrt► <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 /> #i►►rtti+►+#►YYr+i!##1►iii»**###**##i#4#YYYY##ii#r»#+#4Y4Yiiiiiii###Y4Yt#i#YYiii#4tiii#1►►i+#*#►ii+twr►t+ <br /> EH 23 046 (Revised 10/16/03) Page 10 <br />