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At <br />ENVIRONMENTAL HEALTH DEPARTMENT 1 ' /ic, <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 67 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD ;/1 <br />1NIf 11.11..1N1111tNINIfy.IN1f11NNNNNfIfIN1N1fINyyINIfNf yf1N1NINyf N11NNN11111Nf <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 />FACILITY <br />TANK ID #39- dOMU,J d TANK SIZE: /�/N C' PREVIOUS TANK CONTENTS: t� <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor. <br />Address: /moo 156X 5_J % City.. 4!!!�al_)/ Zip:. 7 c;-'2 <br />fs. <br />Phone # (209)_315-k6/ 7$ Date' Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contracto??r. <br />Address:_3 <br />d 43oX 5-7 —City: Z-40/01 Zip: 9 S J_ <br />Phone #: Ze _. -346,?-6;1,75 <br />Authorized representative of contractor certifying through signature below that the <br />manner as required by Cal EPA. <br />in an approved <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />%n1 K S 7_ accepting tank and/or piping. <br />Facility <br />VAZ <br />Address: cz zY /,�r,�,•.!/` "!JJ C� /YJ/�✓ City: Zip: 452- <br />Phone <br />- <br />Phone#: ZD t'�L�fTf, <br />Date Tank Received: <br />Name: Tltie: Signature: Date <br />�STcrL /'il'i,�� ra: S�tiNiTz�"/� ST�tL /�/2oJ✓c 7'S' <br />ADDRESS / rJUO' rOGSv/)7 fZRil iZ9A1GNo C.t�,2JctJi¢ q� 7yL <br />/-130)Z66455 TU : �01Zul f/i/� lwe" <br />/�//�/.✓ 6 111VA65 9C/9'2S;, /li OS Ti -J 120. t) ✓)l/Jnl iE l94 r 9 • 9 y �j! <br />1'Na.�E 4 (c <br />EH 23 046 (Revised 10/30/12) <br />%2- <br />