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ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1 SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> ' UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - 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 Departrnent 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.+ l 1 <br /> FACILITY NAME: `�Tbc�c mU� Yrot` QI^CkA l` <br /> ' FACILITY ADDRESS: �6 ( [A ) t L �l�Y Dlr � r-o r�t tCa <br /> TANK ID#39-0S7 '7f'i TANK SIZE: Soc) PREVIOUS TANK CONTENTS:�c'vkl�E iz t <br /> SECTION 2-To be filled outbyby`tank removal contractor: <br /> ' Tank Removal Contractor: dot_VA&n ?1 t l[to l C4 V_�­ (Z-4"A t <br /> Address:, 0 X:1 (Lf� City: Zip: <br /> ' Phone#:(�3y 1 gZ �S- 2 t� Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: _JCI V A4.'ri 0121 Q W.1 GoV.gZ aj&&trbt,. <br /> Address: K `Z 1 19,L] City: . OL V♦ Zip: 'As IS t)(�!4 <br /> Phone#: <br /> ' Authorized representative of contractor certifying through signature below dratdht 4 ttk-hat been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> 29 <br /> tle: 1. �q .DateName: oGt )Q` TiW : <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: AT i ( otx.d T_ L4 ci i,>Vi.sw_r <br /> Address: Yrs K -L3 u k _City: TV_V l uCit r Zip: I:t I <br /> Phone#:(-Lf-,) (ofS %ZilB <br /> ' Date Tank Received: <br /> Name: Title: Signature: Date <br /> ' EH 23 046 (Revised 07/31/08) 10 <br /> 1 <br />