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%aw <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 completed <br /> and returned. <br /> FACILITY NAME: \ Br,v., rk9�-o <br /> FACILITY ADDRESS: Flw� y F0.r r.n �u t G/� q5- a 30 <br /> TANK ID#39- TANK SIZE: P-5-0 PREVIOUS TANK CONTENTS: tJ rty- I•v e I <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Ad(e/hek -e Geo (�n V 1 r`ov. Meh i-- <br /> Address: 91-37 S L-&w al City: S jug K Fuh Zip: Rs alt S <br /> Phone#: ( `al ) Ll(.,-7 100(- Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: if/A 166cel l2epCrvJ:Royytvtc4A-f p <br /> Address: "�R / 5���"�w 0 City:—feed Zip: s,S IS <br /> Phone#: tocuq ) W? -1006 <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:c, ,tt� Title: hdf.�A Zr- tom Signatu Date s-26-Dle <br /> 711 <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, storage,or disposal facility <br /> accepting tank and/or pipping. <br /> Facility Name: eS Ocas_ En prase n <br /> � pIAddress: P Q - Sax City:jf �O Zip: <br /> Phone#: (ZUq ) <br /> Date Tank Received: <br /> Name:,�JPl YY11 YP2 Title: e QY11 Signature: ( Date 5-2(0—C%2 <br /> EH 23 046 (Revised 10/16/03) Page 10 <br />