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07-22-' 14 14:45 FROM- T-014 P0008J0012 F-019 <br /> 0 <br /> ENVIRONMENTAL ENTAL HEALTH DEPA T:C F,- T <br /> SAN JOAQUIN- COUNTY <br /> Tellephoue; (209)468-3420 Fax. (209)468.3433 JUL 2 ;G 2614 <br /> UNDERGROUND STORAG5 TANK r MPOSITION TRACKING REC6ff ROI°ViANTAL. HEALTF <br /> aYt�rtrrrrat+r+ta+raarti+rartttr,r+tttr:4Lx+vxarxraRYFMtrt�rx+rarer+we#rr.*ax+xi+xk+arrila�+vo-1 rKifraxARrx�+xaxxrx --�� <br /> SECTION 1 -- SJC Environmental Health Department's Tar* Tracking Sheet shall accompany each tank affixedQW§%JMENT <br /> identification number, The Tank Tracking Shim is to be rettimed to the Environmental Health Department ypj30 dans 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 /> FACIL#TY NAME - <br /> FACILITY ADDRESS: <br /> TANK ID#39- TANK SIZE: _/-�? PREVIOUS TANK CONTENTS: <br /> SECTION 2-To be filled out by tank removal contractor; <br /> Tank Removal Contractor;--- L V 07 >+/V ! t. S_V_�Lv I cz/ <br /> Address: i* Lpa� yr 4L t City: zip: <br /> vc/ f Zip:.Phone* ( ZVG=)!6-21 - '2_S"' Date Tank Removed: "' <br /> wsr,awxxreXr:tie#ic#dkt"#�4�fY`.S+*VCYr�'•1CVnk�9r�Qf�*9riFytle rrkku W Ysdr;b#ievFaF*lr#re6sTa#ilritk*Yrd'**irYeir•k*#,4Yt�'hls#�I*&��•�i,tx��Y#�+�r*yy�lyy��y��ey4�Ys7k�'dC*Ys <br /> S TION 3.-To bs filied otit by emt actrsr"de t atira�lar k"' <br /> Tank Decontamination Contractor: <br /> Address: b - � e4,�,1 ' C- City: t et Zip: " <br /> T— <br /> Phone <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 /> ir'k+t{ot'k'k#'XfNwe'kye'f�e W W 9rdeW W W w+kwkib**#ie*tFi1*44'k:F�'it'*�e3e'M7k;P1kiV'�`kAkYr�Y'§MW+ei�4Y9'vW±kki1^RRfYlr kir(eahFst XIr9aA dcitk*k*ebtF'k7t-k 7h#f**�k7eYrMtt#'li Int# <br /> SECTION 4.To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: f tO Y ct•"-- Y"t ftl ra <br /> Address: D a r r , City, 1 4"� Zip: I�S_00 <br /> Phone##: <br /> Date Tank Rsoeived: <br /> Name; ttfe:_ <br /> EH 23 046 (Revised 10/30112) 9 <br />