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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. 11 <br /> FACILITY NAME: `1Tt7c�P[)Cv�u� cz .ctd t` <br /> ' FACILITY ADDRESS: -16 1 i.t ) + (,j L4 V--,04- . r-I,. r_L J=w, <br /> TANK ID 039-(5-5A-LS t{3TANK SIZE: PREVIOUS TANK CONTENTS:��4-F M <br /> ###YY#YYYikWiiY*###**##*###*Y#+##+k##+4YY#YY+Y#YYY♦#+Y+*YWYW*##Y#i#***#rtwkYYwY#Y##****w##wYY#Yt#Y*##w*#***# <br /> SECTION 2-To be filled out by <br /> tank removal contractor: <br /> Tank Removal Contractor: <br /> Address:,C� 1`�OK -71lo� City: cp�tItA-yt,. Zip: 'Er�4— <br /> Phone#: <br /> ' (y 3c 1 b1 C6 (� T t Date Tank Removed: <br /> ' SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: �uL HW 0-1 kart ta.-,AC,t.Lw. CLoVA ZLt ,tet,"pt, <br /> ' Address: City: to,�k \ Zip: "AS p I <br /> Phone#: `LO g y Yi —&8 s�I <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: Se.aT i j Title: �t VI 4 WT Signature: E.5 1 _ v,q .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 /> FacilityName: (1t-ei�y;; LoLLA-r L ca v C army r- <br /> Address: Y+ , o& -2-3u `6 City: TA-tn�ujt Zip: <br /> Phone#:(10cl (P(uC6 - "('319 _ <br /> tDate Tank Received: (2—— <br /> Name: Signature: Date <br /> ' #++k4#rtrtt+##rtrtrtrtrtrtrtrtkrtrt#rtkrtrtWk�k WrtWk#k#krt####kWk#k###irtrt##+#krtYrt###k####Wk##+t#t ##rt#######+rtkt#W##rtrt#+# <br /> EH 23 046 (Revised 07/31/08) 10 <br />