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0 <br />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 />SECTION 1 - SJC Environmental Health Departments 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 ADDRESS: E::4 -v7/ _E::4-v7G/.kfr)S19V <br />TANK ID 1139 - Pr lt ^) 6- TANK SIZE: ?///"J C PREVIOUS TANK CONTENTS: r� a <br />xx+++++w++++x++++aw++x+++++++++++x+++++++++x+++w++++w++w++++++x+++++++++++++x++++++x+++x+x+++xx++xx+++x+ <br />SECTION 2 - To be filled out -7 <br />b -y tanr. <br />k removal contractor <br />Tank Removal Contractor. ✓i /Y/ ; /e Int Ole /n/(� <br />Address: hD 5 / X 3 city: Zip: �S -�- <br />Prr'r rrG <br />Phone#:( 201),3�j00'6/J$ Date (Removed:_._ 7--2.6-1�4 <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination. Contractor— -57,-1 /7q/1/zr7,6 d// /iJG <br />Address: 0 SOX 35 City: Zeo/ Zip: C/ j L 7`z <br />Phone it. e6/%S <br />Authorized representative of contractor certifying through signature below that the tank has been deconta inatact n an approved <br />manner as required by Cal EPA <br />Name://N Signature: / /Lr nafo 2 2e,` <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storil e, or disposal facility <br />1�' C /-yNF.To accepting tank and/or piping. <br />V <br />Facility Name: <br />Phone # <br />Date Tann <br />Name: 4j <br />SGNA)/Tic/z ST_tL PRpp✓c TS <br />ADl)/2ESS / L.d00' rOGSe/y! iZvi4v iZ9n9CNC/ C�cJcrJA 9j 7�1. <br />98's -� <br />ri36�'6�4SS Tp /'0/?G�ifR/7 /•✓e,, <br />l'i/o,lE (Z-0 99 T 4f -C),r 5/Sn1ATw,?� <br />EH 23 046 (Revised 10/30/12) g <br />