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0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />fNt11fNINffNN1NNfflNfXNNNINfff11NINNNMNINf1{NN.....NIININ. N1fNNfN1fff <br />SECTION 1 - SJC Environmental Health Departments 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 <br />FACILITY <br />TANK ID #39 - Z O 1159/ 6 TANK SIZE: PREVIOUS TANK CONTENTS:�ri <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor._ �JZln 11101?12,E 0/e /,✓G <br />Address: L e) <br />city: zip: GlS'2 <br />Phone#:(_.Z097) ,3 (j 8-(p / 7 5 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "dacontaminating tank": <br />Tank Decontamination7Contractor _� i/hd <br />Address:_ a UoX 3 �5 % City: Z4901 Zip: 2 S 2. <br />Phone#: Zt' _3 6�6/%$ <br />Authorized representative of contractor certifying through signature below that the tank has een decontaminated in an approved <br />manner as required by Cal EPA. <br />Name:Title:l �2- 2�e'%o2 Signature: Date,, <br />SECTION <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />V T nl K S Toaccepting tank and/or pii�pin�g.. -r� �, .,,i <br />Facility Name: e91?&)f/f0 /,vc P/J A,-i/,��f- �,.Ji-i /1/!1 //., c; <br />Address: ;�z 9 9 S, /?/>`P City./ eV Zip: <br />Phone#: 7-0 lell'2-9/- <br />Date Tank Received: -3' % 14 1 <br />A 1)01?CS s <br />- Pilo„ gest <br />r/3t �'6G.4SS <br />EH 23 046 <br />.S. <br />S C-hH,1Vi Tz, /Z S r� L �/�o f) ✓ c 7�S <br />RvRJ qj 7zL <br />Tu /A/C-, <br />/IJ)arss 9 9 9 9 S, 40S7_1,61 /20-4i> ✓/J4,ITF, ,4 <br />t 4 (Z-09) <br />C'•9 • 9 � s�C <br />