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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 />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 fadlity. The permit holder is responsible for ensuring that this form is completed <br />and returned. l e <br />FACILITY NAME: nJ.-%CRC�k%/.v%�`//d�1A // ANS/Ty/S7�IC7- <br />FACILITY ADDRESS: 1-5-3 3 �!% <br />LE/I 7 L/ l <br />TANK ID #39 - 7£J i 1 V'590 TANK SIZE: DOO PREVIOUS TANK CONTENTS: NV'c/ O/C /���Q <br />SECTION 2 - To be filled out by tank removal contractor <br />Tank Removal Contractor. _ - <br />✓ihy //WU/e t7t ole <br />Address: Po 13/))( 3 J 7 City: e_" o /o i Zip: Gi S -2 5% I <br />Phone#: t 2 oc71__ 36661 75 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination <br />G <br />Address: 0 L�oX 3 t5;7 City: Z 01-2 Zip: <br />Phone #. 6 9� 6/ 7 5 <br />Authorized representative of contractor certifying through signature below that the tank h ee decon inated in an approved <br />manner as required by Cal EPA. <br />Name:z ZM724 Title:L._�9.Af.///�C'.T iZ Signature: Date2,-Z4 i <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, stc6ge, or disposal facility <br />T nl K S Tuaccepting� tank andd/orf piping. <br />Facility Name: <br />Address: ,5� Fg9 .S', 4,:ws 71- <br />,,,1204D city:,%_4_)TG4 Zip: 95`326 <br />SC-1YA)lrZe5 5.�j6EL r'/Zov✓c YS <br />AU,)r2FSS / L c/Op f OGsv/�7 r2v%9t) iRAn9G//C� C0,1 044 9;)— 7`%•Z <br />{�//�/,✓6 /Qr),7Rfsr 9 y 9 9 S. �i NS 7"i -J R�s.+Ar) ✓./Jilnl iECq C•9• 9�3�G <br />(2.099 Ci Z �) yrr S/sniAi✓,?r ' <br />EH 23 046 (Revised 10/30/12) 9 <br />