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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 /> SECTION 1 - SJC Environmental Health Departments 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 NAME:CAL 7.R*A11; ///6ht11/RYA/ !?•3A t 24 4/.Il, <br /> FACILITY ADDRES&N.R. burner 1110/ra/a�Z g107) I11•ekel S'fjref �in�wy ('/9' 9rtJL <br /> TANKID#39- TANKSIZE: Y00-/i•///wr PREVIOUS TANK CONTENTS: CZ&,fo /NE <br /> SECTION 2-To be filled out by tank removal contractor: <br /> _ Tank Removal Contractor. GeoCo n GOOD 17'en�I1 -n e <br /> Address:316,9 rod, 1/4 Ile), Dnury 41,FDU City:f?-n C( l/�i,tZlp: ClS7S/e7 <br /> Phone#:f 9/6 I ?S-,) -9//�- Date Tank Removed: /2' S/-/5! <br /> *z##*zz*****z*##*z*#rerzzz*z*z**********#*###*****##******z#***z*#*#***##*******#*#*#***###*##**z*z**#*#z <br /> SECTION 3-To be filled out by contractor"decontaminating tank': <br /> Tank Decontaminatlon Contractor: 4'eor O„ nSv /V''-4 frr S e <br /> Address: ve oFCi �gn �d`M`w Zip: 957 .1 <br /> r <br /> Phone#: 9( /G 1 8S_19 - 9//S— <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: Slgnature: —'1 ate <br /> SECTION 4-To be signed and dated by an authorized representative of the trealrnerH-�4o2ge;o '•rA facility <br /> accepting tank and/or piping. <br /> Facility Name: r m q Ile'14 <br /> Address: /.3(2 eVolYc_ 42 -/( J 7 rr• f _Clty:.Serer w", nAA, Zip: y'S`f <br /> Phone#:c 6/6) •V5/SV- 33 d e <br /> Date Tank Received; �( •�f/�`� / <br /> Name: it^]OJ L i Y r t`!4� Title: CKcQr &I Vn!�: Signature: Dat,_124LDIN <br /> - EH 23 046 (Revised 07/17/14) 9 <br />