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0 <br />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. <br />FACILITY NAME: 54A:,&a I.t Rz--Ioy,9L %4_4Si T dl S/e/c 7- <br />FACILITY ADDRESS: /5___. <br />TANKID#39-0 011 /3 TANK SIZE: 66700 PREVIOUS TANK CONTENTS: 111a_ <br />SECTION 2 - To be filled out by tank removal contractor <br />Tank Removal Contractor: �.Jj /T/ ;ND/� ®/L /%46. <br />Address: Po 3o X 3 5! -7City: e—, C) Zip: 2i-2- Z X <br />Phone #: 12 o i) 3 6 / 7 S Date Tank Removed: <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor <br />Address: o L.kX 357 City: Z V{-21 Zip: <br />Phone#:( 369-6;/,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 />Name:, %Z, %X'%%W �oz?A:Ey Title:( %? ,J 70 2 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 />_ <br />Facility Name: Cl/657C t��F - %f. L7d/ kir ,✓/ <br />Address: city: %21,KI-OcA zip: "/ 53*,1 <br />Phone #: ( z0)�r <br />Date Tank Received: <br />Name: Title: Signature: Date <br />T� EL i' �i,v� -r S �f/ z11/ —Z t /Z 5S 7� � L PRO 0 ✓ c 7-5 <br />,q L)))/2 FSS 0— /O& S 0/� izeML) i A40-10 Co,?,)va,4 9 7yL <br />�c7ri /Z6t4SS TO /ORi,+{sfR/� /n/k�, <br />{ ///�✓� Ar)7AE'f s G% % y 9 S. �NS %i� j2i�>Fr) ✓J%f-�/%EC9 C•7�• �i�3G <br />Iii/a,4E �d (Zy�f) <br />98 -2 - <br />EH <br />ZEH 23 046 (Revised 10/30/12) 9 <br />