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,as vlwi� <br /> S� <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 /> 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-::v rittiiu3#hdays of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensurJng�t f this form.is <br /> completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS -?(D SC . co rAz-M=Lx- <br /> TANK ID#39 NK SIZE: 0 C) PREVIOUS TANK CONTENTS: <br /> SECTION 2-To be filled out bytank removal contractor: <br /> Tank Removal Contractor:_�}l�1� <br /> `` V AO1n <br /> Address:, -7 1 oGk City: 'A\,1 tK0LA Zip: C( <br /> Phone#: 53 0Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: .1C7L V,-4-0-1 �,2,rt �L—O\O-Get.,, <br /> Address <br /> � I 1� K `Z I I9 5 Gity....:f�c.k Lkl^�, Zip: <br /> Phone#: <br /> Authorized representative of contractor certifying through signature below tkaflr "as-been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title:_4W.- 1n.3' Signature: £. a. ..Date <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: <br /> \t jj(ys-r (,CP W T a U c tnr pt,•r <br /> Address: 4'� tC 'Z3 (y �f City: T1-y, u e t Zip: S—�o I <br /> Phone#:(-Lo 01 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ********************************************************************************************************* <br /> EH 23 046 (Revised 07/31/08) 10 <br />