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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 - SIC 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 /> FACILITYNAME: 51fb t(l VI \\ icCs1ti� ekt3+ (I <br /> FACILITY ADDRESS: IL 6 H <br /> TANK ID#39- � 73 TANK SIZE: l DOn PREVIOUS TANK CONTENTS: OWyt <br /> SECTION 2-To be filled out by tank removal contractor: /u <br /> Tank Removal Contractor: y-A Osn <br /> Address: ��c—� �g'dt City: PAI V-VZip: <br /> Phone#: Date Tank Removed: <br /> SECTION 3-To be filled out by contractors"decontaminating tank": (` <br /> Tank Decontamination Contractor: C�byvinAmn ��z��Z01Lzl��. ��C IA¢ �N, <br /> Address:!f •© �ch k �1 I IS<G City:Zip: qs�/o f7 4 <br /> Phone#: s( 3, ) 8 7$ 10 Ir'S <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. ,,pp <br /> Name: �o o 0➢ ,Title: t�0yx,-% c* Cxb(0= 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: l,( JI�-S C CJ.d"C �GiW V � V-049,14-17- <br /> T <br /> Address: P,�21c x 2.3�{LI� City: <br /> yl.y� r Zip: g S 3 $ I <br /> Phone#:( ?Wn ( ' FS <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 07/31/08) 10 <br />