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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)469-3420 Fax:(209)4.68-3433 <br /> rRrl.rrR.!l4rii#rO+ UNDERGROUND STORAGETANK#DIS+OSMONTRACKING tRECORD <br /> .itrratirttt4ttttr+F.# <br /> SEC'T'ION t - 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 retamed to the Environmental Health Department !ytthin.30 days of <br /> acceptance of the tank by the disposal or recycling facility_ The permit bolder is responsible for ensuring that this form is <br /> completed and resumed. <br /> FACILITY NANT: t+.A.l_ -rp9td1 A- QA-r, L.-+d.- ,!A 172. <br /> FACMITY ADDIRESS:�-4,7 i C-tkra 51'0 C,1G'i W C� C1!92-0 7 <br /> 140 to <br /> TAMC ID#39- 2 "TANK SIZE: 1210 0 D�1. PREVIOUS TANK CONTMM:��K-_ <br /> rrtr+rtrta.rrr•+rrr•rrr#rr++•ir+r+••♦rrrrrrlrrrrrraalrr+rrrrr•+.rrrirraiirra•ar++rr••rtst•tr.rrr..rar.ra4rr <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Co:ntractor. 1 "ice ' ASSQ��� <br /> Address _! <br /> Phone#:(qo�) } t a b lQ 't P 2Z Date Tank Removed: <br /> t tVttratr ttti4tiV+Y4artrt VVtVVr•rrr>rt titret Vf it trifrVrVr•rtrrrrrFiVMri V+rV#a4Varit•i V4irtf rfVtiVf+tt�4ttti.a <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontaminationontractor.n1CQh lha;tjDh_��l i <br /> Yd on """*" ►° � Cis <br /> } Of -rc..r vl V 0 ra.& , (/I pros <br /> Address: City: Zip: <br /> Phone#,G _..— <br /> Authorized representative ofcgntractor ocrtifying through signature below that the tank has been decontaminated In an approved <br /> manner as required by Cal EPA,. <br /> Ntune.� Ti11e: Siguature Date <br /> rrltr►.t#.4rtirf r.+l..+.r.rttat•+rrit�rrat.r+++iia r+•rrttit++rtt+iit*so******$*r 0 W 0 l t rt•tfir tV Of V f♦♦tttrtt4 <br /> SECTION 4-To be signed and dated by an authorized representativ, f t tttsen storage.or disposal cility� <br /> accepting t k and/or pipe <br /> Facility Name: <br /> Address- City._ -- Zip:- <br /> Phone 0: <br /> Date Tank meived: o — <br /> ` r <br /> Nam . Title; �f /// tom/ Sigttatnre Date <br /> t�� <br /> rr!#t•a•t!rlt...rr.•rrr•4rrrrrr•rrr�rttr �Vritsat4tt •tt`ititt+#if4tri Yr4r4tat Vtr.arrrarrtV•tttt <br /> F-1-123 046 (Revised 11121106) 10 <br />