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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 t — 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: / <br /> FACILITY ADDRESS: 12r�D i� lA)I I�hh V�1(�U� <br /> TANK ID#39-a��r'J'16U TANK SIZE: �n.PREVIOUS TANK CONTENTS:T r��`�m UI I WI Q <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: a S� S 11 110,1 <br /> i O-n l Heol /a Y►n r,h�U»�1' city:_ 'Arvin � 1�11�zip: <br /> Address: /�,�./� �1 <br /> Phone#: L I t!' I ) (nh� 0 0 L� Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: ra awu It/ ' <br /> cu�-lOU e-1 �S1t�y\l l9Wd• City: 1G1Yd�,l�la—zip: qD� L 19) <br /> Address: r � <br /> Phone#: ( �� ) VJ9!}Z lbc) <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: <br /> AddresslI ()I W • �V%6001V Unf�l a city:�(�Ik-II�YII� zip:Om o �� <br /> Phone* 99 <br /> Date Tank Received: <br /> Name: <br /> Title: Signature: Date <br /> EH 23 046 (Revised 10/30/12) 9 <br />