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r.. <br />.i <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION I — 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 form is completed <br />and returned. <br />FACILITY <br />FACILITY ADDRESS: gi Q N• 1-� u n +zr 1 S foGn i c�Pf <br />TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br />+fi4»fiw»ria+#*4#arsaaks*a4»»»»»»*»»#iaaaaaats*»*»w*»**+*rarts»****fi+afiw*asss**#»*ata+rrtassa+fi#rrraass»»*rata <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Eno irao 'IP.�'fd EP91aeertn5 Rnd 6pgbi i '49C, <br />Address: 5-0 / farIL cen fgr Q/'t vim— City:_Sdnk 4-4 o.- Zip: 97210 <br />Phone #: c?/'( ) 667-7,3426 Date Tank Removed: <br />##4#rrt##44#*#rt##aa#fi4fi#*rta##t#ifi#*#*i4#rts*4*##*irtiwrt#**###irt+iri#t###tt#rt#44##ti4#####ttti■ti#»ttii#i###ttt <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination <br />City: <br />Phone #: <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 />r+a**wwrt#4*tri#t#++rrta#4t4*trrrt#i#*#**rrrt#+#t4*fiiiw####*rrrrwaa4#firrti#r#*#rifiirai#fi##tiii###tirtw4a4#tfi#tw <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 <br />Address: <br />Phone #: <br />Date Tank Received: <br />Name: <br />EH 23 046 (Revised 3/15/02) Page 10 <br />City: Zip: <br />