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0 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 />f 111111...11M11f 1111M1f ff 111ff11111NIf11111111111MMMMM1111Nf f 1f MN11M1N1M1f111111f fff <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 reading facility. The permit holder is responsible for ensuring that this form is completed <br />and returned. <br />FACILITY <br />FACILITY ADDRESS: 5 3 3 E-%!27 ei,212�;44 <br />TANK ID #39 - S— JJ�1n(/� A((NK SIZE: OO lOOiiPREVIOUS TANK CCONTE7NTSS:U�tKyi�!/JED H� <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor. _ ✓i /IBJ 7z7a/e Int DSL /,JG <br />Address: Po )( 7 City: 4/-ew l Zip: <br />Phone #: ( 2 0'1 ,3 �j j /� s Date Tank Removed: <br />r+wwcawr+»rrww+rww++r+r+wwww+rr+ca+rw+++caw+w,tw+w+w+++rca++rww+++++caw+r+coca++w++caw+w+++w+++coca++caww+++www+r++w <br />SECTION 3 - To be filled out by contractor "decontaminating tank': <br />Tank Decontamination <br />Address: ( [SOX 3 5 7 City: L 0/� / Zip: S .1 7 <br />Phone t. 36e6/%5 <br />Authorized representative of contractor certifying through signature below that the tank has b n d con inated in an approved <br />manner as required by Cal EPA. <br />Name: 71 //y0/�I�IZ Title:( �2,�1 /�j�17 /Z Signatur , c �( <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />T,accepting tank and/or piping. <br />Facility Name:_ /Ca— I?L%ofl1]'r ✓ <br />Phone #: <br />Date Tani <br />Name: <br />City, % 7441 _Zip: 9573� <br />s civ A)< rzc /z S 7. � L PRO 0 ✓ C TS <br />i9f)l)/2ESS / LOUd- /'r?GSo/y! R04t) iRA,0Cl•/f7 C0,10 V4 9.:? -714Z <br />�egowe� (g16)9gs y-TIo <br />1-i3t e644SS 7-0 , 1-01?a4/ip /�✓U. <br />/'i/'i,✓6 <br />1101211`6-s 9999 S. �iNST�-J /2�9�r) ✓�J�1JTFc9 c•9• 9�s�� <br />l'110.46 -# (z09) �/ff7 . �) 912 S/S�t1A%✓,7t ' <br />EH 23 046 (Revised 10/30/12) q <br />