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0 <br />9 <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 t - 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. �tq > <br />FACILITY NAME: �ni:jl /dy/�kl ��F�/0,0& /'� -'V' S/ 7- d / 57rflc / <br />FACILITY ADDRESS:: 1_55 3 3 91!2 <br />TANK ID #39 - �'U �g `TANK SIZE:DOO IO�(hREVIOLIS TANK CONTENTS: Che,5!l%E D 6;Fgge {.ti's <br />SECTION 2 - To be filled out by tank removal contractor <br />Tank Removal Contractor r./%/7i�/�O/?I2t ®0&/1,4e,Address: Po IU X3 -7 <br />_/ City: & ew / Zip: -.2i- _12 <br />Phone #: ( 2 0 9) 3G,6 / 7 S Date Tank Removed: <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: //%l 2&/Z[,2AF D/Z' /,Jc <br />Address: e D /3ox 3 7 City: Z01-21 Zip: i <br />Phone #: Z4i _.3 6 li 6 <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 />� <br />Name:, ei �7',fTfJ Z/ 0/?PTitle: X2..1 Z/(,�r(.%p 2 Signature: Date <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />V T nl K S T,accepting tank and/or piping. <br />Facility Name: WES 7 Coo,; 7.674A/ i 6werzil) <br />Address: // Sada -7276/UE>Z city: 71-gGock Zip: g5 �yj <br />Phone#:3 7.5' <br />Date Tank <br />Name: Title: Signature: Date <br />S7:—:iZ ��'infs �o Sch�11/TZ�/Z S�� L 0PRvDJL75 <br />A01)/2F5S / Z.vU()' /'QGS�/.r! /2e)%4il %Z9niCt/t7 Ck�.2Jck1/¢ y� 7y -L <br />est (�/6) cI?�S <br />C1 _ <br />r-ic3t= A'6lFSS TU /'D/2t,+{s92j� /�/�, <br />{ // /.✓d A0)Ats s 9 J �1 � S. /�I oJS Ti.� {2�9,fFli ✓%i9-�I TF C� C9 �3 � �3G <br />-6 -d ( Z-0 c/ C/ 2 moi-) 0r- Ci.-n1Ai✓Jr <br />1.111111`?I1B.1 <br />