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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. <br /> FACILITY NAME: (:�:i b Cr\LtD1A a..Qy%a (-e-e <br /> FACILITY ADDRESS: -7 0` b—) + W u DVCZ -C6 4—t b o <br /> TANK ID#39- TANK SIZE: 600) PREVIOUS TANK CONTENTS: uj,, <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: �C) V ;A0w Vc?'y1z O� c=iy`, Ca V.Q,1-Vii,.r.��`CL-, <br /> Address: i C), ( AGI City: cLyELn Zip: C'["0 <br /> Phone#: k, Date Tank Removed: l-2 <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: vii \1,hZL�, U kkw r" C2tt`(9�^ <br /> Address: �cQ. —j 16�. City: 1401 v-L-i L-i Zip: � G <br /> Phone#: 3 0 <br /> Authorized representative of contractor certifying through signature below that the t k has been decontaminated in an approved <br /> manner as required bey Ca�EPA. ` <br /> Name: Qr oy, �\�O Title: :!t i.t ms`s u Signature:14 z k"i. Date (_2 <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting ank and/or piping. <br /> Facility Name: �" �c ZIAI,., � L ` 5� c <br /> Address: -1 City: �la�.�V�i. Zip: _r 0 <br /> Phone#: -2-0 E? 14 3 4 <br /> Date Tank Received: <br /> Name: b1 l.i. C" Title: Signature: <br /> EH 23 046 (Revised 07/31/08) 10 <br />