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0 <br />E <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 410 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />f f 1MNNf 1111111NNN1NNf NINNNNNN1Nf Ift1111NNN1NNf If11111Nf Nf N111f f N1f <br />11N1t11f11fNN <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 f <br />TANK ID #39 - / r 1%""E TANK SIZE: /moi PREVIOUS TANK CONTENTS: r� /ti e <br />++++++++++++++++++++x++xx+f+x+++++++x++++x++x++x+++++x++x+++x+++xxx++x++x++++x++++x++»x+x+x+x++++++++++ <br />SECTION 2 - To be filled out by tank removal contractor <br />Tank Removal Contractor. .JJ In 1Wj9/? r7t Ole /„ Ie <br />Address: _ I'D 13,0,Y 3.5 7 City: G e) Zip: <br />Phone#:( 2091) ,jG��/ JS DateR�' R moved: J_ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamina0onContractor._ =3 / 71,11?r7,E <br />Address: -,e o Sox 3 t5,7 City: � r7/✓) � Zip:__2 S L <br />Phone*.? -c 3 6 l6/7�j <br />Authorized representative of contractor certifying through signature below that the tank has dontar,�inated in an approved <br />manner as required by Cal EPA. <br />_.--------------- <br />reatment. <br />SECTION 4 - To be signed and dated by an authorized representative of the t, storage. or disposal facility <br />p% accepting tank and/or piping. <br />l/�yNam / <br />Facility Name: g%Nl4Zt� /-��C/• <br />Address:_. / t_/ %��C�11 _ ��O/�� City:�A p 4 Zip: 45 <br />Phone # z a <br />Date Tank Race ved: <br />� I" <br />ame: Title: _ _Jr V�Q I Signature: Date <br />c .S c-N,II/ TZC'/Z STS L PRO L) V L Ts <br />A00/ZFSS / Ld00 r�OLSt)/y! f2vi4J RAV010 C�iJcrli¢ qj �yL <br />r, 6t �'6�•9SS <br />70 <br />f ir'i.✓6 RpJnfss 9 y y q S, �i r -1S T. -J Rc��v ✓yJ�1�JTFc9 <br />EH 23 046 <br />