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_W <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Faz: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 <br />completed and returned. e4:5,81ZZ1,V Rg.9L SST97r <br />FACILITY NAME: OL AM (Z /!7/nl _ IL /1A1 -,4w -7- /� T <br />FACILITY ADDRESS: .,Z I �� S G L /OfZ� l p 4 <br />TANK ID#39 -e)�11R � (r, TANK SIZE: ®�(� PREVIOUS TANK CONTENTS: (/sJ <br />.._ s+r+r+rrrtwrtr+»rr+*+*rwr+*+++»*r++***r++»st+4++r+++wrww+*»*rt*++tttt+rrtr+t+**rwrr++rrrrr+++++rtrrtt+rrrrr+ <br />SECTION 2 - To be filled out by tank removal contractor:. <br />Tank Removal Contractor: <br />Address: 20 3 D X' < 3 5 7 City: G&D / r� zip: Gy <br />Phone #: ( )y3 Z -"_11S__1 Rate T" k -Removed: <br />++*+srtrrr+r*t*+rt+*++r++++srr+»+*rr+++»rt+++++++tr++++rrr+++ttt+rrt++rrtt++++++++++r+tr+++++++++++rt++»rtt <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: ZJT— 7�rf 6/G <br />Address: �0 QO,Y ,j % City: LyD / Zip:f" Sd 'f / <br />Phone #: (¢2 42!�) <br />Authorized representative of contractor certifying through signature below that the tank has been decq t"[ed in an approved <br />mannIr as required by Cal EPA. 1 <br />SECTION 4 - To be signed and dated by an authorized representative of tVtreatmek, Stora <br />g , or disposal facility <br />acceotingtank and/or piping. <br />Address: /oZ DDD /© 519er1 /3Zy/J Cole / <br />City: COR O(/ij Zip: %> % �4� <br />EH 23 046 (Revised 17/31/07) 10 <br />l <br />