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Jan ., 3 2005 3 : 33PM • No . 1983 P , 3 <br /> SAN JOAQUTN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> FMF;Ffi#MMYWYSFMWFYM;MlWYtfiNF;YNFM4YMt;YMwFWw;;Y;MFF;FYNw#M;FFY#;fi YFY;FFNFWw;fiMMYYtfiFwrtWrNfifiF;;M#FMfiYFtFNMYrt <br /> SECTION 1-SJC Environmental Health Department's Tank Trackiug 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 ffithin 30 day$of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed <br /> and returned. 11 <br /> FACILITY NAME: C)P_CV `AfL_3 S n n 1 L-J,4YLr_ \%h V S t5 <br /> FACILITY ADDRESS - G!Q 0— <br /> TANK <br /> TANK TD#39- 0 1 TANK SIZE:,S LPREVIOUS TANK CONTENTS: US L <br /> MNNFrfiFFYfi#FNNFWFFl;NMSFNMW;MWsfi;WFFFM;NtYt FFFYtFMFFFYYtfi;YFFsfifi FYFFM}FYsFMfi;WWFFFYYW#1 MNWtWFwMwrtFNF;rtFFMF! <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_ bj / L prIv C S4 <br /> Address; Po '?),wk 3 o 346 City s teat�o .i �Zip: QI S A 1 3 <br /> Phone#: o q Q' 1 q Date Tank Removed; <br /> WFNMMNWFFrtFFfiFFM;YwfifiFfi;NrfiFFfit##rtFYrFF;w;FF#firtwr##F;WYtF#NFWrrFY;YF#NfirtrkNFMWWF#M;fi Wt#fiFFrtr M#FNFYtr YFFwNrM <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor, �l N 0S r&v t 1t...9 N W-CN�W t. <br /> Address: Q__! io <br /> 1) _1 LQn r '� 1��/ J City: a l5brQ WA- q MO <br /> Phone#: Q) IOtP "S -I 7 <br /> Authorized representative of contractor certifying through signature below that the tank has been deoontaminated in an approved <br /> manner as required by Cal EPA, <br /> Name:btky G �1 VW W,y Title: V D Opt$ Signature — Date r'7-44` 014 <br /> YrsMFNFWtFFFFFs#wW#t;FFfiNFsfM;NNFSYMMFN#MfiwMYFfirYFFF#fiFFWFtl FYMWF#tMMYFfi F;rtYFYfi MFYNFF;M;rNMFMM4NYF#MWWFt#!W <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: 0_O - �I& (�r %A Kersoit.r.F Co,A_D VW Y4 <br /> r <br /> Address: 1 0 t.1 Z- t 1`1 t", Oki K- City: V W Zip: 9 E66 Z <br /> Date Tank Received: 0 <br /> Name: Title; Signature: Data <br /> ;FNWNY;N;YF#f MNFYs#FWrtMYtFNF;YFSFF;WFrMFFYWFF#F WWtfsfiF;YF#fiF;;;FIfiMWFYF#rtNFrtF#rt F4NW#fiY;w YNr;fiMMYk#fiNNYYWrt <br /> EH 23 046 (Revised 10116/03) Page 10 <br />