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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> rs•rs astrrrtiiiaiiaiatiitraaaiarrr#raarrrraarra•rrrairratrrsrriaarraaraiiiaiiiiiiiii+t#+++a+++t####a#####i <br /> SECT ON I - SIC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br /> identif cation number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br /> acceptarice of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is <br /> comph ted and returned. <br /> FACT ITY NAME: SLA,2ZMEJAI 1 <br /> i <br /> FACT ITY ADDRESS: 0 <br /> TANI< ID#39- TANK SIZE: PREVIOUS TANK CONTENTS: Y� <br /> +sass ttsstttistiiti#rtrriij{"+i!}iiari itiiiii+iiiii+#ittriitiitii+it+#i+##i#ra itii ti+tai tii##t####a##rt•#i#+ <br /> SECT ON 2-To be filled out li' '`-_removal contractor: <br /> Tank Removal Contras r: (' -jam GeJ ay ie-V _c <br /> Addre s: (J i��i �, y��?/g na 9-r, City:✓mc" Zip: ( -d <br /> Phone YM9 Y{ OBJ Date Tank Removed: <br /> I <br /> tassii•a•itttttitiiiirttiiirtaiiiiri}iiirtia#rtrtrrrrrti +a#ir+#rra rrri#aiiriiirtara#airairiiriiii+##rt#+## <br /> SECTION 3-To be filled out by contractor"decontaminatin rr rv. <br /> Tank econtamination Contractor:' tcn' TA-T'1 O.J t�r��. <br /> Addre s::Rni? ae9�_/ IQtroAl O z CityZip:C?SZds <br /> Phone 4 <br /> 4A <br /> Authoized 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 Title: Signature: Date <br /> •s•••, •••aaaaitttttttti++i+tii+tt+ri++ia#ar+iariiariiiiiririiiiarti+rr+Mrirrriiirtirt+rarrarriiiiii++tt#t##a#i. <br /> SECT ON 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tank and/or piping. <br /> Facili Narg ,pu-� �rjr <br /> Addre s:30 UA_� I n k csk� CityruiC�Zip:��j' <br /> Phone#: Z E) <br /> Date I ank Received: <br /> Name Title: Signature: Date <br /> t••at tiiaa##atiir#i}iitrrti+rtirtrtirairyiaii}irt:+rii}}iirtirtrtrtrtrtrrrrtrairtr}#rtrt+r#i#rrtriiaiiiir rt4i##ii}irt#a <br /> EH 23 046 (Revised 17131/07) 10 <br />