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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQM COUNTY <br />Telephone: (209) 468-3420 Fax: (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 forth is <br />completed and returned, 0GB/GL,a AC9 L SST T� ��t/ES�/ylF.✓i„f <br />FACILITYNAME: 6613fl? IWZ,J / C <br />_ <br />FACILITY ADDRESS: CZ/ 5:;�_ S <br />TANK ID #39 - G -7 TANK SIZE: Q Q PREVIOUS TANK CONTENTS:�f�J/� <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: ifi/ ._4� <br />Address: P O S O K h 73S7 \ City: GfJ/D / zip: �iS'�t 5,1 <br />Phone #: ( � Z, S7 0 I Date Tank Removed: /0-7—/0 <br />SECTION 3 - To be filled out by contractor <br />"decoutaminating task',: <br />Tank Decontamination Co`nttractor: <br />Address: �� QO�C 7 City: Z49,0 I ZiP: <br />Phone #: Ccg g .� i 9 S 9-f-fi l <br />Authorized representative of contractor certifying through signature below that the tank has been 06contayinated in an approved <br />manner as required by Cal EPA. <br />SECTION 4 - To be signed and dated by an authorized <br />—accepting tank and/or piping. <br />_._ Facility <br />or disposal facility <br />Address: Ze: DOD z�z SD�rI ey/J 1 y`Valoj % S7 �GZ <br />City: CDR Jodi} Zio: <br />EH 23 046 (Revised 12/31/07) 10 <br />V_ <br />