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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 />ff11Nf........111M1111NNN11Nff1Nf�11f NIN1NfNNN1fIf1111f111NNN1N......... Nftf111NNf <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 <br />eturnedFACILITY NAME: 511A:&iZV14 R`y,-/U,yaz 724-45-17- dl 5-5?16 7 - <br />FACILITY <br />FACILITY ADDRESS: 3 X457 <br />TANK ID#39- Fi0//iJFi�TANK SIZE: j6aa© PREVIOUS TANK CONTENTS:(, Ste%% O/L <br />+xx+++xt++x+xtxxx+xxx++x++++++H+xx+++xxx+++Nx++++xxx++x+x+#+xxxxx+xx++xxxxxxx+#x+#xx++++f.xxxx+lxxxxxx++ <br />SECTION 2 - To be filled out byr. <br />tank removal contractor <br />Tank Removal Contractor -7--- e % // - i <br />0X -7 <br />?Z D/,/ <br />Address: Po i3 3 5 / City: <br />Phone * ( Z0'1) Date Tank Removed: <br />xxxxxxxxxx+ixxxx4xxxxx+++++x++x++xxx+,t+xxxxxxx+xxxxxxxxxxxxx+xxxx+xxxxx++xx+xxxx+x+++xxxx+x+x++xxx+++++x <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. -5//%7 &21Z,7/' <br />Address: L�� / 7 X57 City: Zip: Cl S z/ <br />Phone#: ae -3 <br />Authorized representative of contractor certifying through signature below that the tank has been diecontarflinated in an approved <br />manner as required by Cal EPA. /� //711 <br />4 <br />SECTION 4 - To be signed and dated by an authorized representative of th"atment, storage, or disposal facility <br />T nl K S 7-0 accepting tank and/or piping. <br />Facility Name ?,to- go2r/ <br />Address:r�' //y1%�• _ <br />_ Zip:..}• <br />Sc-h'NITzc/z s7�=j�EL r'/2ol)✓c TS <br />Av1)dtSS / Z.C)O0' /'OGS0M iZe7Av iZ9e&)1V Ca,1Z0clV 4 9-)— %-�PL <br />ride=rz6�gSS To ; �ont;J.9/tp /n1G, <br />{'i/'i,✓3 J,goJaEss 999q S• �i�fsT,-J /2��r� ✓�77�JTFc�9 C•q• 9>�j� <br />.4IF'd (Zo9 �/rci cam) L` (Y C/ L+1AiJ.Jr <br />EH 23 046 (Revised 10/30/1 <br />