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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 />.....,..»....»..»..................»».......»»..»».,.»...».....»..,,».....»....»............ <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. <br />FACILITY NAME:_ 541J:Aatll �421 S Z <br />'IC 7 <br />FACILITY ADDRESS: 1-5--3 3 ElS% el,02 ,4V <br />TANK ID #39 - r} TANK SIZE: oZ �G�/O PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank r <br />annk removal contractor. <br />Tank Removal Contractor. ✓i /Yi ZYi )/e f t 0/,/ /.dG <br />Address: Po U X 3 J 7 City: V D I Zip: S 1- <br />Phone #:( 20'1 ,3G8'ro/75 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. _J /15P7 27,62,?r:7�g 6/,/ /nim <br />Address:_ d Sax 3 7 City: Z40101 zip: -1G5-2- r/ <br />Phone #: 3 46*' 6i <br />Authorized representative of contractor certifying through signature below that the tank had. n dAcontarPinated in an approved <br />manner as required by Cal EPA. / �1/ <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage. or disposal facility <br />%A,accepting tank and/or piping. q _ <br />Facility Name:_�%t(�4//X tf"� /l/I�/G. i/'ter/L� r� Z/i��/�9 <br />Address: L . < 5 or �//•'V /40,1 V City: it%T� Zip: <br />Gl <br />ScNNiTzc/Z 5:72�-jEL r'R0J✓Cr5 <br />4DO/Z4 St R0 4f) iZAnICNU CO2JOV4 9-�1- 7,f -L <br />64-f SS <br />// /"/d AJIness 9 9 9 9 S. �i �1S %i�J i2c�.dr,� .'�l'.>n1 T£C9 C•y • 9 � �j� <br />/�ilo.46 � iZarf) r'/fsL • �f-J �i rr S/SJ�1Aid�lf " <br />EH 23 046 (Revised 10/30/12) 9 <br />