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OWA <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />s+srtrtrt»srt»rrtr»**ssx»rtwsrtrt#rt»ss+rtrrt»»rt+s+s»»»srt»»»rss++rtrrts+sssrtsss*rtrtrt+rtrsr+s++»rtrss»r+rts+rts»»sssrrrt++rtpss <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. <br />ee- <br />FACILITY NAME: IZ /19/ni G fc. - //i1CrA.J % LO -7- <br />FACILITY <br />FACILITY ADDRESS: G Z� J `f S L�GI�ORi <br />TANK ID #39 -05I S?WTANK SIZE;(,/j/522_0 PREVIOUS TANK CONTENTS: lfnl& <br />»»»»rtswrw»rtsssxs»swsrsx»»»sssxsrt»wsawrtwrt*ss»rtrtsssxrt»w»srtxrtwssxrtrtrt+sssrt»rtw*ssw»»»»»*s»+srt»»»»»�»»»»s+rtsxr»»» <br />SECTION 2 - To be filled out by taukremoyal contractor: <br />Tank Removal Contractor: <br />Address: 20 BOX- <br />- i 35-7 City: G10-17-10 <br />D/� I y Zip: 99.54 5o <br />Phone #: (�) 3 Z-2' 5r t Date Tank Removed: / 0 — // — 10 <br />»»w»rsssssr+»rtwwsss+rtww*sss»»»srssrt»s*+sssrt»swwss*srt»rt*wsssrtrtssss****s*ss***+*****+********.*sw*+******sss* <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: ✓-117/;1 Zi O/Ze p1L 1,4C.Address: & 60)ctrS / City: LOV I zip: CA 70/ <br />Phone #: <br />Authorized representative of contractor certifying through signature below that the tank has been <br />manner as required by Cal EPA. <br />vt tnPiug. <br />Facility <br />- -- 41cess-��GOD �y�ol D/YI Cif &/� city: c �JW/4 zip: %.<7 Z <br />Phone #: ( )_ 9d _5� --le-la <br />EH 23 046 (Revised 12/31/07) 10 <br />