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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> UNDERGROUND STORAGE TANK DIS>POSMON TRACKING RECORD <br /> rir tr»ir ri++Yrs#s11 r#rar#r*Errir\rrrrrrrrrrrrrlrtEAwa++♦Ewiliti##trrrrrrrr*wt*rwa#iawiliririirlririYrr#rrir <br /> SECTION 1 -SJC Environmental Heahh Dcparunent's Tank Tracking Sheet shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Sheet Is to he 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: %M- CAA tT09-bA A—C4S .L r cL ;Oe�172- <br /> FACILITY <br /> 72FACILITY ADDRESS: 47 aPAct4rt c-•" STac1_'1o1-j t r-'/* d1S�td7 <br /> 310�TANK 4,' 12. 40R t, PREVIOUS TANK CONTENTS: Ski t� <br /> TANK ID 1F39• � SI?E. f l� ,.• <br /> Efi#tr#r#r####*frrrYiiiff#*rrf t###rr1#*r*#**r#i*#*arYrrtYarrr#t#Y####ttYr'+F#rr*rrir##f*#i#rr#riYYr##r#irrrr+t <br /> SECTION 2-To be filled out <br /> -b�y''"tank removal contractor. y� <br /> Tank Removal 1Contractnr otb�I'a � ' tssoo olj;tj ,fl�. <br /> Address: "l� r City:lnWk r'0 j I t t�a� Zip: <br /> Date Tank Removed; 7 120 <br /> #rrtEr#ir#rrEY+1#s?fr*rrrrr#rrYr##Yfr#rYErrrrrrrri#rrrrirr#aYr#aYit#ararlMt##Yr###Mr##Er rrr*#*Y##t*r***rrrrYir <br /> SECTION 3-To be filled out by contractor"deeentamluating tank": <br /> 'tank Decontenation Conowtor:l�Pt Cfi!C�AM11►'10�'�DYt WOi�_ �1��'llt�- , Ys� �1J� 0 as 1XW1 C7� <br /> tlrW1 �'d�' C I�st1 rx pry eeGUJ�t. <br /> Address: City: Zip: <br /> Phone 4: <br /> Authorized representative of contractor certifying dwough signature below that the tank has been de¢orrtaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Datta <br /> #rrrrr#rrr#Yrrr#rrr####sssr*rrrrrErE#r##rirrEs#t#wrsrr#r#rrr#*sf*#Y#friss#*##rrtssrr#rstrrfrfrrsr#rr##rrir <br /> SECTION 4•To be signad and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tan and/or piping. <br /> Facility Name: rf <br /> Address Uff city: <br /> V <br /> Phone N:( � p <br /> Date Tank cceivCd. / f 141 �J <br /> Nam . W Title: L�� Signature~ Date <br /> rar#♦+rrr•iii#rt*r*rYriii+Fif rEErra##r•#err#r##•rrir###rirEf###rr# r ##r YErrrir*r#i#rrt#fir!*rrt#a*rrir#rrr <br /> EH 23 046 (Revised 11/1.1/06) 10 <br />