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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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. (^ I <br /> FACILITY NAME: -n d I 1O <br /> FACILITY ADDRESS:j7 <br /> TANK ID#39- 5`l 35 TANK SIZE: �2,Odd PREVIOUS TANK CONTENTS: 10M SLP <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> al <br /> �Gaa GIAkS -l�g <br /> Address: Ivl�t� I ICPIA L`rY/�YVI City: Doi h6 tb Zip:�L-- <br /> Phone#: ("10 Date Tank Removed: <br /> xx*+�*xx�+x�*��xir*�*,r�xr:��r*:�:+x�r*x�*���*�x**��r��**�:r��**��*��*:��*���++x++x�+���+x•�+max«�*rte«**�:� <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: Poo MSS 1� rm <br /> +-�� E &2141T& W& City: —Zip: <br /> Address: 1 r �1 <br /> Phone#: ( 'Jln 1 ✓2� - L42�) <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: <br /> Title: Signature: Date <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:yymv w WW p <br /> Address: jwj w ' ip—MonyrfAclau City: —ZiP ��Ip <br /> ^I <br /> ` <br /> Phone#: ('JLC ) '�t'-A -y,\n <br /> 1 <br /> Date Tank Received: <br /> Name: <br /> Title: Signature: Date <br /> EH 23 046 (Revised 10/30/12) 9 <br />