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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 /> riiitiirrsisiTYYYYWWwiifs#i;rti4WWW#tifi##W4W44ss##;###44WWWWWixii###rt44YWW#ii#irt444WWilsi##W##WWWfiff#i#rt4W <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 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 /> FACILITYNAME: �TOG1F"iri4vrc�tr..ei�Gttlli <br /> FACILITY ADDRESS: -76J L.t J t LL)L4.6 ay- rp I-lc rt-z... <br /> TANK ID#39-B S 1-15 4 3 TANK SIZE: PREVIOUS TANK CONTENTS: <br /> Ww WMwwiiiiixisirWWWWrY;;iiwisi\iWWWrWiitstsi#WWWWwWWttiirssW4W4rt;;Wsttiiw;WWWWWfistitt WWW;WttsisiiWWW;WWisss <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: �traovt ��t'ct.o L t V.+n+ t..1� <br /> Address:llP 0- R,lZ�K 't m4. City: Zip: _ <br /> Phone#:(�, �Z la 2[� Date Tank Removed: I t- S'-D S <br /> #trrt4#rt##ilassts#W#W;Olt!lsisisi4#4WWWtssi4YWY#;Wgssitiii WrrrrtrtYixisirtrrrrWrtiirrrtW#WYgtiiiiiiti##YYwiisii <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: .d�OVt Vna <br /> . <br /> . 0-A -t r,%,o\g.4xw„ <br /> Address: `7 1 to'-, Zip: <br /> Phone#: ` 1O <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. y��y <br /> Name: vg,—Title: 'tart. kjj L-T, Signature:1.J % —Date <br /> Yf WiW WrtWWWWWirifiiri WiWWWwWAaiiiTigiiWW W�liwttq;iWW Wr�iritlilrrttii♦;TTWYwWY Wtiifii;M4WWWWiiiiiWfWWWWfifiti <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: (_c,U-.d-r <br /> Address: 17X �31y 6City; Twln�v�t Zip: S�cS.1 <br /> Phone N:(70 11 1 1p(o tb • (37 g <br /> Date Tank Received: <br /> Name: // Signature: . Date ,mss.. <br /> iwrrttssssaiY#rt#►glittsYii;#M#W�YWiis;#4W44WWWisi#i#rt##44#W4Wkftttr;M4WWWiiistiiWW4Wlssssi;lW#4NWistssi <br /> EH 23 046 (Revised 07/31/08) 10 <br />