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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD N1NNf f f NfNN11NN11ff NN1N11NNff1NN1N1N1fNN11NNftflfflNN1N1N1NN1f f111Nf NNNINN SECTION 1 - SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME:.5,fA ✓OAVIIJ i�/'!f).tfAL 22 45-i T 42/ 5Z -FIC %- TANK ID #39 - t? i %J��Je2O TANK SECTION 2 - To be filled out by tank removal contractor. TANKCONTENTS: Tank Removal Contractor. 7e;W /{/U /e Int off,/ /,jc Address: 10o 13o X 3 57 -7City: 41—al) l Zip: 9, �- Phone #: ( Z. 0 9) 3ol S' 6 / 75 Date Tank Removed: 21 xxx+++xx+xx++++xxx#++xxxx+++xxxx++xxxx++++xx+x++x#xx+xx+x+xxxxxxxxxxxx+xxx++xxxxxx++xx+xxxx++xxx�t++xxxx SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor. .-.�/,-77 7qd/Zi7,g e--)// /n)G. Address: it o LSOX 7) 5 % City: L OD l Zip:_ 9 S L 7`/ Phone #: Authorized representative of contractor certifying through signature below that the tank manner as required by Cal EPA. in an approved —ZG —I SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, ofdisposal facility GTAnl K 5 TvaccepYting tank and/or piping. Facility Name: -gitkAlA t, Ink" %?, x/ -z �_ g %�fpY/ •T�7 ��i Address:l 6 / /T�f) l ini _ / w � City: ,CA) 1Ci� Zip: —9— 6/' �3� Phone * Date TI I Name: Sc-.HA)i7'zc/Z ST,�tL l�,�o�✓c7�S ALWR CSs / Zaor9' rOGSv�! fZvR� i2/9AiGNO C�lCr�rrr/R 9� 7 z � �)—1'/lOnl e st icI/61 `/f�'S - � ii% C7 s/ &.✓A,—v, E ' - ric31=^'6GFSS rp rORcJ/9/tp /�l�, i'i/'i,✓s X41)-)n�ss 99x9 S. /Ii;.fST.-J i2�9.�r� ✓Yl�1�JTFc9 c•9• 9�s�� I�i>lo.4i �1 (�`%) �/fsL • `fL�L� �/S.n1A7✓�7� ' EH 23 046 (Revised 10/30/12)