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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: 5 s b -t'tl Vt \` r ooxx�-�(A1l i• <br /> FACILITY ADDRESS: `I ( r 1 (A)� 1�CSiL t r oGt� � <br /> TANK ID#39-651 7? 3 77 TANK SIZE: t 00© PREVIOUS TANK CONTENTS: LA.y&A,w Dc:9 LA <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: ` .A o%n S G t'CZ ` CPQ ttM o OC� f nr <br /> Address: �X_� �W City: Ak1.g V-VZip: <br /> Phone#:( S3C> $'2 Date Tank Removed: <br /> SECTION 3-To be filled out by contractor`"decontaminating tank": <br /> Tank Decontamination Contractor. o vin 4 m n �t?�t fL O l UZ lti l� W�1/�T�tA Cr <br /> Address:' �D N2cX X �7 1 (.q city: Zip: 4 ssk.&X <br /> Phone#: S( 3� ) $'7SS to 8"S C� <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: �to 0LL Title: J!,,Or,�w Signature: 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: U ` ex/Q C Lem y tr lMQ✓r� <br /> Address: R K Z.3(o `lY City:-r�-A In C{c Zip: Cr S3, g L <br /> Phone#: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> **#++++##+++*##+++++#+*+*++###+#*###rt###++##rt#4###**####t#+#tt#tt##+######+++##rt##+++4###*#+##*####*s+### <br /> EH 23 046 (Revised 07/31/08) 10 <br />