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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 />................................................................................................„,».. <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 <br />FACILITY <br />TANK ID #39 - TANK SIZE: PREVIOUS TANK <br />P' <br />SECTION 2 - To be filled out byy tank removal contractor: <br />Tank Removal Contractor: J% rYi //5/Q/� t�� O/L /,'✓L <br />Address:— Po 13/))( J.5 7 City: Zip: <br />Phone #: ( 2 O i ) 3Ge? 6 / Z,5 Date Tank Removed: <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor d2& /J6 <br />Address: P d 3QX 5_7 City; Le/') Zip: <br />Phone #: Zell)3 6 � (, 1,75 <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 />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />Vaccepting tank and/or piping. <br />Facility Name: E;q 12 <br />p <br />Address: 7, City: / ,�j�t Zip: !l <br />Phone #: <br />Date Tank Received: <br />•;STEL / i�in1� >o <br />ALWIZr s <br />1-41 _ ello.JESt <br />1-131E R6C-FSS <br />/­�//- o' <br />IA - <br />EH 23 046 <br />Title: Signature: Date <br />5 C_ti 41 Tz c /Z S r2-z� L ��i20 L) L/ c 7's <br />/ '1-000- r0& of J fZe)i4il iZ949010 Cry iJcr✓,4 9-�r 7y -L <br />�qi6) `/£SS `f G S'/r_ , C , <br />TP /0Ra4ni,) %A/e%, <br />�4JJatrs 9999 S, /��IST, J i2e�r) ✓n�✓iEc9 <br />