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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 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. <br />FACILITY NAM <br />FACILITY ADDRESS: 1-5�3 3 E9 � % <br />TANK ID #39 / t7/1553/.5 TANK SIZE:vZO�,O00 _PREVIOUS TANK CONTENTS:�I�S� L <br />SECTION 2 - To be filled out by <br />tank removal contractor: <br />Tank Removal Contractor:_ ✓% /"ii 11O/? I2t: ole /,jU, <br />Address: Po X <br />-�! City: el) l Zip: --2i->- <br />Phone #: ( 2 O) 3 j, 8' 6 / 7-5 Date Tank Removed: <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: __i //i'/ &/ 2rgg (p// /ijc <br />Address:_ City: Zip: <br />Phone#: Z�' 36x6/75 <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:/,VW 1110/?t?/y Title:( �2-1 �//� _%p /Z Signature: Date <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />%An! K S Tu <br />accepting tank and/or piping. <br />Facility Name:_JC_Pl !_W®L�. L. 19_1�G�� <br />Address: �.fp,/ ��i /_Tt�15g6!/j/ <f. /% CityAY/n Tl./1< Zip: <br />Phone #: <br />Date Tank Received: <br />;�T�rL j ��yr�� s� � S�h'/1JrTzclZ ST_=�L r�i2of)✓c>S <br />4 0)R FSS /2040 i2/9n9CNU Ca2Jvf1,¢ y j � L <br />� 7 <br />{ ///n/S i4r)Ja�Ss `39' 9 j S. /�NS %ice {2�yrRA /'J7i9.,JiEL9 C•9• 9�s3� <br />jlloX-6-4 (ZJo1) Cifc3, <br />EH 23 046 <br />