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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD SECTION 1 — SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME:CA1_7R,*A/5 H/Cof/N//IY�G (�3�f o� /✓ey FACILITY ADDRESS: /V.to. elv/ner /{/eli#./ny aC(/q/07) A /yoi kel S'1°jeet iJw�ar e-A g9,234C TANK ID#39- TANK SIZE: PREVIOUS TANK CONTENTS: GRSOL/NE SECTION 2-To be filled out by tank removal contractor: Tank Removal Contractor: (3&0e-on �O/fS'U �7r�n�1� �n e Address: 3MP tso/d' 1/4//e,, Drive #('Oti City:/�4n eA" 6144 B ip: 9S7S� Phone#:( 9/G 1 8S d —9//� Date Tank Removed: xtx�x:tt�:t�:t:t��ttx�xxax.<:tx:t�:t:t��,t:t�x.x��:t:t�tt��t�x«��xt�t��xa.x:tt�:tt��.�x�.xt�t�z•aa:t:t:t:t:t:t�a�.�x�x:t SECTION 3-To be filled out by contractor"decontaminating tank": Tank Decontamination Contractor: Poron C Onf4 A,'4, A-, S e Address: 3/40 1/4&e;,w tgli(/ orac? City,( e*106W" Zip: '7S7 Phone#: 9( /G 1 BS7,9 - ?IIS— Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Name: Title: Signature: Date �+:t:t��:t��.:t��:t+t:t:tw:t+t+:�:t:t:tt:t:t:t�:t��:t��axxa:a�.z.�x.�x:t�t��:t��:t��:ez�.�x.:tx:t:tx��tt:r�a«a x�x��•��:t:t:t SECTION 4-To be signed and dated by an authorized representative of the treatment,storage, or disposal facility accepting tank and/or piping. Facility Name: S Ale .14 .one G�irrrn f Address: X317 /Var/-,( 1,2 -// SfieC f City:Sarra"ellly Zip: 9S- // Phone#: ( 9/G ) ,$19'Sr- 3-780 Date Tank Received: Name: Title: Signature: Date EH 23 046 (Revised 07/17/14) 9