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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 /> FACILITY NAME: <br /> ' FACILITY ADDRESS: _701i L&) + ( J LW�Q, -Qt>ac-th Ln <br /> TANK ID#39- TANK SIZE: S� PREVIOUS TANK CONTENTS: A vc�x.9c <br /> SECTION 2-To be filled out by tank removal contractor: <br /> ' Tank Removal Contractor: 40 `n t\,p0w �c3 cczLS� c=kvti �nua C`lC7 1Ar T`r <br /> Address: ? n �r; x 7 I L °I City: t++AVL Wt, Zip: <br /> Phone#:( Can 1, 3�- Date Tank Removed: <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: -3��V"A 05" \ c� a tnxna CIIS "T-r," i 1r^ <br /> Address: �S3 Q o tc I I0� City: RahxJn xn Zip: c -&O T <br /> Phone#: <br /> Authorized representative of contractor certifying through signature below that thet k has been decontaminated in an approved <br /> manner as required b Ca!EPA. <br /> Title: x Signature: Lo k"A. Date <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> ' accepti g ank and/or piping. <br /> r' <br /> Facility Name: �� C(�IS,tZV-t.... ��@�\T�-�t t 0( - , , . ' <br /> ' Address: 0 • Z c9 -7 fJ', r1 City: J���N� Zip: 9 '14 0 <br /> Phone#: &0 R 7 9 T o 3 <br /> Date Tank Received: 1- - �r-o 0 <br /> Name: Z � Title: I�wi Signature: <br /> ' EH 23 046 (Revised 07/31/08) 10 <br />