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0 • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUINCOUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> iiististiii3tiiikiiYftitiit#SstYWkilittfiiitfsWitttttfitiiff kfttiiiifittXiXiiiitiiif iiXii;itiiit RX#tkii#k;! <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 /> r <br /> FACILITYNAME: < b e_`L.1"h, <br /> FACILITY ADDRESS: '70t 1_Z , Q tAr Q tb��fit2� <br /> TANK ID#39- TAMC SIZE: S* PREVIOUS TANK CONTENTS: fAv� a m 39, <br /> it Xi#i X i t iiiii####ktk XR$t#t######XX#ikk##irk#k#######M#MMMMMf MMMMMMtkWWWi WWiii Yi#k WWi%ti 111Y11i Y11 <br /> SECTION 2-To be filled out 1`by tank removal contractor: <br /> Tank Removal Contractor: C w Ko4Ovi C-4 e tj (=kv4 <br /> Address: _t`tt 7 ( Loal Zip: r <br /> Phone#:tS-At> > VAbt a� Date Tank Removed: 1Z- S-0 $ <br /> ikikkki Ri#iiiiX+i#S#tkki#t#b#########R#4#####MWMk MMMMMMMMMMMMM#MRM#MtiWXiikiitiiiRtikif#kR#R#RRM#4#RMMMMM### <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractorkg�-Mczl, R %,L _II tk,(9� <br /> Address: � A,Q o K 7 � � City: aA LA-v+h zip:-q-` 0 <br /> Phone#: 30 - 3 <br /> Authorized representative of contractor certifying through signature below that the t has been decontaminated in an approved <br /> manner as required b Ca EPA- <br /> Name: 1z o �i O uO�K Title: Signature; zo 440i. Date n- C k <br /> iRikltt MMMMMMMMM YMMMt#i FiiiiiiXiXXiX WiiitiiXSR##tifiMMWWMM#FYY#F####Yi;fii#if tt#RRf RiftRt#RbR#bb%btii%tkW%# <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepti g F nk and/or piping. <br /> Facility Name: ns `p �M %3z t:CLp L?�� �'Z'��t L'�i0.L! /� �!� <br /> Address: C) � �� �< c (o °1 City: wl 1 Zip: `1 n to 0 T <br /> Phone#:(r 3D ) 9-79-10434y T <br /> Date Tank Received: Z - C) t <br /> Name: ^ar-� Tide: 5 Signature: ate fes• \-f7r <br /> s#!F#MMMMMMWtFM#sFtkkisiisii!#kf#RRt!*#lWpM#WMMMMFMMMFFsssssskkaRstRMMMMMMFifsskis#fR#i!####MMM####ttikt# <br /> EH 23 046 (Revised 07/31/08) 10 <br />