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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 469-3420 Fax: (209)469-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> awsaswtwwaaswaaalsworn rwsaasaaaslfit##awlaa•#ff aasraa arwrs#wwfwa raaw asaaswrwaai##alxawsw!#as+#Yxxra R#ssa.a ssa <br /> SECTION I - SIC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Sheel 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 /> FACiLTTYNAME: i�di J� �� i Y1�� Srt� SMG _ West µ,'SL. Sclovf <br /> S fie,, <br /> FACILITY ADDRESS: .moi' 15 7iQ+C(n C� <br /> TANK ID#39- ^3�� `3�w11�(�(%l(T�7AMC SIZB� PREVIOUS TANK CONTENTS: kJ<S f <br /> iii ilaxaiasf as•s aTx s�ss`+�y iifaa Ya/x axrgai4WMf asaY saa LN xxai YMaaa tsass a u as ss aW war rls+a+rs+pVaVa4rrwf ssNess <br /> SECTION 2-To be filled out by tank removal contractor: ` <br /> Tank Removal Contractor. 'D e ( f-A 01 <br /> Address: R0. -4dK !(075 Cin,.W0C7Wf( Zip: `i —176 <br /> Phone#:L 1 4P600' 9W4'/ Date Tank Removed: 0 7 <br /> aalaalallaiwwf#awlias+s+aa++• #040R#a#aa rwMwMW#saa!la+ wrr**Wa #a41Yf#f <br /> SECTION 3-To be filled out by contractor "decontaminating tante <br /> Tank Decon4minadon Contractor .�{ t17O(Cj=f f_j_Q --latWO <br /> Address: YJ JVX 1& 7 5 City: D/ Zip: 77 <br /> Pbone#:53V <br /> Authorized representative ofconcractor certifying through signature below that the tack has been decontaminated in an approved <br /> manner <br /> -mas required by Cal EPA. <br /> Mame Z!ye-. .Sc, rAr;Y Title: _Signature: <br /> irrali+F#•+wsrawwasasa aarrxlwww##a Ya1#tasrsa wssaswrai Ys#latwsaaaa aaai YYwaalra#wswawaa iiia#!!w+#sa+a+ess+♦ <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: F,;-l; I /f <br /> Address: G;`J� n p E� '.n 7l( A . Ci1y: k e k"A j Zip: <br /> Phone#! %( (Q 1 A7j 5" / 313 <br /> Date Tank Received:_ -1 /L7 / A O U '7 <br /> r.h <br /> Name: n P�oc-eq5 " j <br /> . P.S �P�r X Titk: , 1 Sigaemre <br /> ate / O <br /> aaawNssraaaaxap#ors Nsaaassa#at+raawasrslaa#Y#f#Rwasraaq Nr!# YwN Yrvsww+waaaa•NxaN#MlawwsraaYxs#star <br /> EH 23 046 (Revised 11/21/06) 10 <br /> Z 60Z£9£Z0191 Puow40R1 1 0 3 d6£Z1 Zo Zl AV <br />