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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 DISPOSITIONTRACKING RECORD <br />,...,.....»,.,,».........................................................................*...,.,...,,.,,. <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 <br />FACILITY <br />TANK ID #39. 90/ 17j8'/ j TANK SIZE: 42e PREVIOUS TANK CONTENTS: USS/J Ole' <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor,_ L 124: D/L /�C <br />Address: 1?O X % City:. LC7/) / <br />Phone#:( ZPi) ,3Grl 2/75 --Zip: .2 <br />Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. <br />Address: ��X �� 7 City: 07/9 <br />ff / Zip: <br />Phone #: 3 Ug—li/7{ <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:�iTIQ%/.J �N ?fJry Title:( 47J///j e- %o2 Signature: �,+e <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />V T nI K S Tuaccepung tank and/or piping. <br />Facility <br />Phone #: <br />Date Tank <br />;STEL � i/�in16 �o <br />Aa)IZ�Ss <br />Pilo„�rst <br />ri 3t ,Q6G-9SS <br />5' r /YCL <br />157 <br />ma <br />City✓�/4�l�i� Zip: <br />Title: Signature: Date <br />5C-/YN/rZ)t/Z S7�Tez Pi2ov✓c TS <br />, V16) 478,6-.- <br />C) <br />R��7f) iZ9n9GNrJ Ca.iJcr1/¢ y j �`iL <br />Ti.) /'0 Rt ✓s9/L/J lwe-, <br />/90)nFs s 9 % 9 S. 40S rl,,) i2.�eRr) <br />//e 4 E -4 (2-0 9 <br />EH 23 046 (Revised <br />✓y/�9n1 %£C.% C•9 • 9 s'��� <br />