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YAtic 11 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 469-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKUNG RECORD <br />♦Yii Ii YYYYWYYf itiY tY#YYY{{Y{iit Yf YYYY YY{YYi Y{Y WYf YYYYfYYYW}Y{i W.YYYY YY{{Y{{YYY. WiiYYyy tYYYY YYYYi\farf.YY.YY <br />SECTION 1 – SIC Environmental Health Departments Tank Tracking Sheet shalt accompany each tank affrXed with its site <br />idanttfication number. The Tank Tracking Sheet is to be returned to the EnvimnmmW Health Depa[tasent within in 3o days of <br />acceptance of the tank by the disposal or recyoii4 facility. The pormit holder is responsi6lc for ,assuring dra[ this form is <br />completed and returned - <br />FACILITY <br />FACILITY <br />TANK ID#39-Q�} �`6 .I%TANK SIZE: OO'O PREVIOUSTANK CONTENTS• �� S <br />irrii Yti MYy YYtty YYiiYYYW#WWYty YW!\iaiY iylarYiiYWWYYaYii Y\YiYaYylrytYYYYYiWYY}ill}rti...Yya YYa YWWWYYM YY}Yea <br />SECTION 2 - To be filled out by tank removal to ntmetor: <br />Tank Removal Contractor: <br />Address: _�s cl L Di �i e", ,4 i <br />/(i� p': � / zi� LL <br />Phone p: 20 G a �j S _ Date Tank Removed: <br />YfYYY Y7 vYYYYYYbi H{ HYY W Yii Wi YW YYY{YYWi YYWYYYY{M...IygYYWiY+Yy YyYq YW##Y#W YY YWYi Y{Yi{W......YYSWY...YY <br />SECTION 3 • To be filled out by contractor "decontaminating tank"; <br />Tank Deconp�^inationj Contra/c[or._� <br />Address: / "m Ll ©J� <br />7-5—Z <br />t� City: <br />Phone a;(�r%1 .�Ci/ ?–r/J/ ?tom <br />Authorized representative of contractor certifying through signature below that dte tank <br />manneras <br />requiredbyCal EPA, has been daoontaminatod in an approved <br />Name:[// 2 %.J <br />Signature: _Date <br />Yi YiYay WYyyfY\RNliYfyf iiiit Yi Wii Wiyti YY iYy WiiiyyWYyiYtiWaiy YYYitwiiY ilii YYi WWyWrt Wiy WYy Wiyiiy{.YW. Yis Vibi <br />SECTION 4 - To be signed end dated by an authortzad representative ofthe treatment, storYtsa, or disposal facility <br />m <br />acceptn tank and/or piping/, �+ %% y��f n <br />FacilltyNa,: t;//�� ! `Y�',l Crz <br />Address: I oC OG/' ���SifJjr� �(//j, City: rP,t,o4 y '� <br />Phone#:(� 2—zip: <br />Date Tank Received; <br />Name:_ Title_ <br />Signature: .Date <br />Y Yi iYY tYik Wyi Yyy ytk\iYWifi WititYYWfiYy iitYYi VyYkWY iy WYYyiWWyYyyy Wliiyy WiiY Yi{YYYIWi Wyi Viy VYyY WiiyiyYi YYiY <br />FH 23 046 (Revised 6/9/06) I0 <br />