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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> #i###iX*X***XXXXX#X#*##XXX####iiXXX##*XXX###iXXXXXXX#####iiXXXXXXXX###i#XXXXXXXX##**XXX#XXXXXXXXXX#XX##X#XX <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 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 /> FACILITY NAME: �ie Dl C(.� f1C) SGC^�Lf <br /> site, <br /> FACILITY ADDRESS: 315 Z5. �� � S1" 7-;e+(� t <br /> TANK ID#39- TANK SIZE: PREVIOUS TANK CONTENTS: <br /> ##X##iiXXXXXXXX#Xiii#ii**XXXX#ii*#X*X#ii##*#XXXXX###i#ii#***XXXXXX#X##ii#ii*X#XXXXi#i###iXi*#i#i*i#X**iXXii <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: _�I ) e ( �A 01 L F;," ��U��i99G�� L✓`� � / <br /> Address: �/l . trk I�o75 City: G�dC�I/ 1,Zip: 7740 <br /> Phone#: ( a) 4�b� Date Tank Removed: <br /> #XiX*X*XX#XXXXXXXXXXM*XX#XX####iiiX#XXXXXXXX#Xi###i###*###i##ii#iii##*#i*#i#iX**XX*XXXXXXXX*X*#*##i#######X <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank DecontaminationQQContractor: �Z. y(L.-�/ -f, � -s-72 J/ /C / <br /> Address: A .tom x /&-2 City: ZZ),eyd(G{ilsi' zip: -/ 3_7 7 {� <br /> Phone#: ( JV > 44 Z - >g4 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> #i#ii#XX*XiXii#*#i#ii#XXMXXXXXX##XXXXXXXXXXXX*XXX*###*ii#XXXXXXXXXXXXXX*Xii#iii####XXXXXXXXXX#i###XXXXXXX*X <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 /> FacilityName:77_-Ce <br /> Address: '15A�aliz U City: <br /> Phone#: ( [Q ) A ?) 5- 1 ,313 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> #iiiiiiiii*X**#####iiii#iikiiiiiXXX##ii##iXiXXXXX#i*#i##ii##XX*XXXX*X#X*XiiiiiiiiiiiX#XXXXii#iiXX**iiiiiX <br /> EH 23 046 (Revised 11/21/06) 10 <br />