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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone:(209)468-3420 Fax: (209)468 433 <br /> UNDERGROUND STORAGE TANK DIS3rOSITION TRACKING RECORD <br /> aura♦4Rt++t rrrt trait rata...tirarrrrrar Yr+rrairrlir raarrarrifi#rrrrria#srr#ssarrarra rrarriaYr�s W�kat rrlrrr�ar <br /> SECTION 1 -SIC Environmental Health Department's Tank Trucking Sheet shall accompany each tank affixed with its site <br /> identification member. The Tank Tracking Shcet 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: ?s�sr cA ut-Fo¢h1%A- "AS <br /> FACILITY ADDRESS:��{-7 �'rr— C A'tifF+ <br /> 3'f0 So S'(PS� <br /> TANK ID 939- _ __TANK SIZE: 12100061. PREVIOUS TANK CONTENTS: fe'ASOP-4 Ke- <br /> rti4i#riitRi iiririrartrriar►W#aririr•til►air.•rararrrrrriaWaraiiriiRtiiiaal Viii i#tt##t##W#i#i#ir#t#####rir+ <br /> SECTION 2-To be Elled out by/U.n�k removal contractor. <br /> Tank Removal Contractor: _f'/t�{1�`!'A i ��S U -e� 1;/r�-�y_ <br /> Address: -10-e � w+ City.:Cb 1� 11S Zio!,L <br /> Phone 9:f t�-]1� F �� Dam Tank Removed:_.__.I_ I;•.�D � r <br /> aRa#a►a#a♦##ri!►!##iiiiiaai#iii#iii•i►1a####ir irir►i#a►•iitrirr#Y#ii#►#►iii•/►irlri#r►•a!i#art#riirairirii it+• <br /> SECTION 3-To be filled out by contractor"decontaminating tank": ""� <br /> Wank decontamination Cantractorj 1 t'LOCt1 Oy% 4 AQJ ,Elp l"{�Y r+AW 01n St?fibL 1?2 }D-0 <br /> 0t:5 paa.+ 0 f t►..a. V,,"V0ftt4tq CA Qsv r e prvcQ,A v)If- <br /> Addrass- City Zip: <br /> Phone 9:(_ ) <br /> Authorized representative of oonu- ctor vsrtifying through signature below that the tank hes been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Namo: Title: Signature: Date <br /> rraararuisairitttiaattaWaiiris►rtir#stirs►•itisat#•ailrs•srsisiessssessss•s#asst#isssisrrs►#rra#iisrsRsrrr <br /> SECTION 4-To be signed and dated by an authort'ud represent*tire of tke treatment,stioragc,or disposal facility v <br /> accepting ten and/or piping. Gl�{� t✓ G'L ��.S N P-44,,�r�C4'x-0,714 <br /> FacilityName: <br /> ^r) U4-d,�, <br /> - <br /> Address: City: I <br /> Phone#: <br /> Date TankR Lived: -7' Si, < N <br /> Name. Tula: 5ignat=: Date <br /> #tilt*►a•tit/lilttri►#r►iW.#�riirrfi#fill#••lYa►tririil►i►►!!i!•!#• • ••!!ii!•iiaaiia►iriilaaati ai aaali tail <br /> EH 23 046 (Revised 11121/06) 10 <br />