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0 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 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 <br />FACILITY NAME:_ S/1ni .�nA190/.J U1uA <br />FACILITY ADDRESS: 3 91 <br />TANK ID #39 - bI I -5I TANK SIZE:Ck. <br />r-- <br />PREVIOUS TANK CONTENTS: <br />. —n <br />SECTION 2 - To be filled out by tank removal contractor <br />Tank Removal Contractor: -1 j /%i //iCI/? Int ®/L <br />Address: Po i3ox ; % City: Ze)o l Zip: <br />Phone #: ( Z. V i ) 3j jf� 6 / 7 $ Date Tank Removed: <br />zzz+++++z++++++z+z++++++z+z++++z+++++z+++++z++++++z++++++z++++++++++zz+++++zz+++z+++++++++++++z+z+++++++ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination � Contractor: .�//1P1 //�d1Z[2AF d// /�jc, <br />Address: ee <br />i i3ox 3 `j /-7 City: Zip: 9 S 2— <br />Phone#: Zd' 36*'6175 <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 />117/�� <br />Name:M1RZ1N o_I?Pt/ Title: X2.1 7 /Z Signature: Date <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />01 accepting tank and/or piping. <br />/A.JK S To _ q <br />Facility Name: 6665; 7 CdC0,15-/ '7� .COd / �' lrn I_ <br />Address: a 77&--tti/U /2 City: V_,?Z0C/f Zip: U% 5 .jam% <br />Phone M( zVi, <br />Date Tank Received: <br />Name: Title: Signature: Date <br />;ST�rL r'�'i,��s >a � S�h'i1)iTzE/Z s�_=�L ��Zo�✓c 7`S <br />fi01)l2r SS / Zc/v()- /�QGSd/y! /2t)i4v i2An9CNU C�?Jcr//t y� 7`/L <br />rirst �'6�-955 Tp <br />� J <br />/ ///,✓d <br />110211`6s 9 7 % `/ S. /�rrIS T. J i2�� A ✓J'7.9 J %E C9 C-% 9 �3� <br />EH 23 046 (Revised 10/30/12) <br />