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EN-VIRONMENTALT HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*s»rt+*sx******xxrtrt***xww»***ssz*rt********+***z+***sxrtss+***ww+**swxwtrt*+*****rtwrts****z*ss*******»****+r1»** <br />SECTION 1 - SIC 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. �G�/L�/.J ,P�9L EST! /�dESy�F-✓�`� <br />FACILITY NAME: 041191Z /WIA) / != <br />FACILITY ADDRESS: ,2= / �� S. iq)u / <br />TANK ID #39 - Os 1g9TANK SIZE:_ 60 PREVIOUS TANK CONTENTS: Z/,rO& <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: .> r�-/� %�f�dlai�� Ole- led e . <br />Address: P0 So X t:3!5—/ City: Z_&D I Zip: C15S ,4 91 <br />Phone #: (Q�& -.32- 9' Date Tank Removed: /� ^ 2--/c2 <br />ssssrs»»r*x***zzrart**zss*»zzzssrs*zzzrrt**szw**srz***s*r****s#ss*s*sw*****ssss*szsrzsrxsszrzrssrrxzzzsrrww* <br />SECTION 3 - To be filled out by contraacttorr"decontaminating tank": <br />Tank Decontaminati <br />on Contractor: .J//y) 7j7 /Zl�f 6/L /j/C / <br />Address: �D 601 City: LoOI Zip: <br />Phone #: <br />Authorized representative of contractor certifying through signature below that the <br />manner as required by Cal EPA. <br />SECTION 4 - To be signed and dated by an authorized representative <br />g tank and/or piping. <br />Facility <br />- - -Phone #: <br />Namd'.yS �F (_;: �L�i tiPD Title; <br />EH 23 046 (Revised 12/31/07) <br />L <br />10 <br />in an approved <br />storage, or disposal facility <br />%sem z <br />