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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY 41-61 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />.......................»....».»....»..».......»....»»..»,»,.»,»,.»»»...,..,,»........»». <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 forth is completed <br />and returned. �� <br />FACILITY NAME: S, A:&ay1-�l ��`%/U��QL //� d5-1 % d / S7,-elc 7 - <br />FACILITY <br />FACILITY ADDRESS:/ ->r515 11--4S/ G/'✓051V <br />TANK ID #39 - Nf' ANK SIZE: ///nl C- PREVIOUS TANK CONTENTS: 1., <br />SECTION 2 - To be filled out by tank removal contactor <br />Tank Removal Contractor. �✓% hn /Z2�azz : 0/e 1A, <br />Address: ISD Sox _35 / -7City el—d/-) / Zip: C/S <br />Phone#:( Z.0C1I 315'.f-6/75 Date 44rrK Removed: 1�1 <br />SECTION 3 - To be filled out by contactor "decontaminating tank": <br />Tank Decontamination Contractor. �5 //5;7 t2,9 6/L 1,J6 <br />Address: 7 sox 357 City: Zoo/ Zip:_9 y 1 - <br />Phone#: Ze 36E6/75 <br />Authorized representative of contactor certifying through signature below that thoAank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />SECTION 4 - To be signed and dated by an authorized representative <br />.2 +JK S T.accepting tank and/or piping. <br />Facility Name:__/(�%Gl <br />(mf a <br />Phone #: I Z 17 <br />a <br />Date Tank Received: <br />treatment, storage, or disposal facility <br />0 <br />cty/l�9rr�T l zip: aiS��E <br />�ST�tLri�inf�>o� SINN/Tzc/Z S���L r'l2oD✓c TS <br />AU))r2ESS / ZVUO' 1 OGSr]l;pl r2e7i4L) RAA9CY10 Co,2Jca,4 <br />ri3E�'S�4SS TJ I-Wa llo /we-, <br />/moi/'i,✓s Ar),JAFrs 9999 s, 190ST1-J /2v-40 ✓rrl�lnlTFCq c9• 9 336 <br />/la.4E (Z09) 9 2— - 5/Sat147,qj /2- /3 -/ <br />EH 23 046 (Revised 10/30/12) 9 <br />