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<br /> APR 2 4 2M -4E EIV ED
<br /> ENVIRO ENTAL. !✓
<br /> ENVIRONMENTAL HEA L' P'ARTME1 '6 205
<br /> SAN JOAQUIN COUNTY ENVIRONMENTAL
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<br /> Telephone: (209)468-3420 Fax: (209) 468-3433 Mj:D�pTAEicA)T
<br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD
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<br /> SECTION 1 - 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 NAME: /�/yC �CC�(!/�G� S`j�'//Oc/ �s'j /���©,.,Z,•,�,j
<br /> FACILITY ADDRESS: �7 J "„tl� 14J�Ai)b/
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<br /> TANaK�ID 39- TANK SIZE: 5S50 PREVIOUS TANK CONTENTS:f(sed B/L
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<br /> SECTION 2-To be filled out by tank removal contractor:
<br /> Tank Removal Contractor: Z�1 2aG d✓G 1-,)e .
<br /> Address: 20 3a2X '3.!5' 7 City: _-Zip: 9_ T
<br /> Phone#: ( 2?JG/) Date Tank Removed:
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<br /> SECTION 3-To be filled out by contractor"decontaminating tank":
<br /> Tank Decontamination Contractor: ✓/ 71,/ey/J ©/L /,Jc
<br /> Address:�t�� V0� 3O57 City:
<br /> Phone#:C 2,&) Z 9/
<br /> Authorized representative of contractor certifying through signature below that the to s een cont inated in an approved
<br /> manner as required by Cal EPA. -
<br /> Name: //17�iC//-�X;1?n� Title: 5:% e1 f 7616 Signatur Date �`1
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<br /> SECTION 4-To be signed and dated by an authorized representative of t treatment,storage, or disposal facility
<br /> accepting tank and/or piping.
<br /> Facility Name: AC�9 efQ
<br /> Address: 29r/ /Cl, //� Rr]-�<Q City:4&a27cFC,4 Zip:
<br /> Phone#:
<br /> Date Rcived:
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<br /> EH 23 046 (Revised 10/30/12) 9
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