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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />««ra«uumr««««»ruurw+«r«rru«««a«ar»r«rr«rrrwr«m«m««naaaur«roa»r+r.ur»+ua«umr <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. �t-meq <br />FACILITY NAME: n% .�CRQJ/N ��`,�i%f�/l�A //2/PNS/ T 421 Sr/C 1G 7 <br />FACILITY <br />TANK ID#39-R � S' TANK SIZE: 6C00: PREVIOUS TANK <br />SECTION 2 - To be filled out by tank removal contractor <br />Tank Removal Contractor. J- /Y/ 7/1D/e r2L: ole /,'/6. <br />Address: Po Oox ; / City: e_" eW / Zip: <br />Phone #: t 2 O % ) 3G* 6 / 25 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. .-.J //%J &&,2,e o/,/ /.pill40/o� Zie, <br />Address: .83 O 30X 5 7 City: Lp: G% <br />Phone#: Zai -36,y6/75 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />,nn ee > �- _ <br />Name:Lt/�TJQ//� �/S/D/?,�� Title:( 2.a T/tilte'. 702 Signature: Date <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />V �nIKS TJ accepting tank and/or piping. <br />Facility Name: W657Cc14S7.6(Wit)/ <br />Address: Is2,6Z Ir S4A/a 7i 6-1yEiZ city:%vAZ/_Oc/k zip: C' 5 3el <br />Phone #: Z V <br />Date Tank <br />Name: Title: Signature: Date <br />�T�tLti/�in1d ra A%PRoI)✓C75 <br />Atll)RCs5 0 r'ae,scvv7 RevRL) r2.9aeN0 <br />riot �g1:95S Tv <br />/ //a✓a /�r»�fFsS %99'q s. ��sT,-J it��:�r� ✓.✓�9�iFC�/ cy��s3c <br />(Z-0 Cl cisco <<I r, C c, r.947TCYr <br />EH 23 046 (Revised 1 <br />