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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 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 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 <br /> completed and returned. 1 <br /> FACILITY NAME: i f�c�-IY4Ut �;rest�.. �ctd <br /> FACILITY ADDRESS: IA) 1 LA)CL y__1 CNV- 5 r-0 e[l_ <br /> TANK ID#39-6 S�1� y 3 TANK SIZE: ©G PREVIOUS TANK CONTENTS: <br /> *********************************************************************************************************** <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: L\_V-4pLj ?, l z (Z.-O t-A t:t ;_� (ue,0, C <br /> Address:,O, 1l.K Z ((or)t City: IA kl FOLIA zip: (5��0 <br /> Phone#:( C, - j `;(� Date Tank Removed: D$ <br /> *********************************************************************************************************** <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: ���V"0.1 z %_(A <br /> Address: City: cJL, ,t zip: <br /> Phone#: e-, <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 /> 11 Z"_ <br /> t l <br /> Name: of i a�1,,�,�,,�. Title: �ifsZdy,In•T Signature: e.�q 1 u .,Date <br /> *********************************************************************************************************** <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:Li.-5, ( "A-r (L. 4 <br /> t 6 } <br /> Address: ���� ti X Z3 U "g City: 'TK tip l u t Zip: S ': <br /> Phone#: `1 f,a(Q "(-7 <br /> Date Tank Received: I Z— S!-09 <br /> Name: Signature: Date <br /> EH 23 046 (Revised 07/31/08) 10 <br />