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MAR. 18. 2005 3:44PM CC,RD BLDG SVCS NO. 0495 P, 5 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONI_YIENTAIL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1-SJC Environmental Health Deparhnent's Tank Tracking sheet shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Shcet is to be returned to the Environmental Health Department tivithin 30 dates of <br /> acceptance of the tank by the disposal or recycling facility. Tlae permit holder is responsible for ensuring that this form is completed <br /> and returned. <br /> 1~ACILI'I'Y NAME: <br /> FACILITY ADDPSSS:4 a <br /> TANK M#39-_A TANK STZE; pMvIOUS TANK CONTENTS: L-N L <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: <br /> Phone#:( 5jQ_)C6%4-A3SQ1iQ1Date Tank Removed: <br /> *�R*fit3t�F�+lll(rX.�#*#b&Wyk**##t�F#�W�s##:t:t��k�e��vk#knMkraa*9r�kW#tx:eRfi�N�NW�kttt�k��k*�N'�##t*#*rt*+r###tk*W*�kt�k*sxe�m�hk'�F'##tY*'I�MW <br /> SECTION 3-To be(tiled out by contractor"deconaminatintn " A'CE� t -FIUA g <br /> Z-0 <br /> Tank Decontamination Contractor: Wk1x- UF_ eE-W itSH'Eb <br /> Address: nen, City_moi 1 NDP-Q Zip: <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 /> Name u Title: <br /> MlL,. Signature: Date 13= _ <br /> #*x*##**M%:###�k�NWW###�*WMW�s#tp�cx*W:Y##�xk��M�i�k#xW��%�kW�4#*8�%�Rw�kW#s�##�k+NW#�k##�3rW�hW*#:kxa��d��k�W�:##*x�k#•Wd�*'k##t�*�kWW�s <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: 5 <br /> -City: N1Oh4D Zip: <br /> Phone <br /> Date Tank Received: ;gp <br /> Name:_ Title: Signature: Date___ <br /> ****s""****t*****'k#x*E**** #fi*M**** **** ***********:t##**�*�4W*##*�*WW###�*M*��Ni�BeY***�C*WAN* <br /> EH 23 046 (Revised 10/16103) Page 10 <br /> 35251 ot.� �E1�lC`.kL Y+I�STE N1AN�C's��hET�'f", ��C. <br /> YYt*tn� , , '��rtt�,r� 4 C_ t" 8GQ ) <br />