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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: (r::-TvG�a �MVI_IQL.OLAL` <br /> FACILITY ADDRESS:7 D ( A + 'l��u� Tip r�[ 3X� <br /> TANK ID#39-0V l S4 TANK SIZE: S00 PREVIOUS TANK CONTENTS: <br /> SECTION 2-To be filled out bytank removal contractor: <br /> Tank Removal Contractor: jot\-Ih-401n Syrya_ot '-V+ <br /> Address: C), aux -11 V1 city: L4ily�.A Zip: _ <br /> Phone#: ( . 30 ) g j r6- (-1, (; Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: .d L vw 0v1 �)17 A p-.o�el V%� , Cnn 01w�MA.. kko" <br /> Address: U t k�c K `1 I is 5 City: t�OL Zip: �OA sa)0 4 <br /> Phone#: <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. I <br /> Name:Sc OK[,-l c���_Title: �v""&WT Signature:I o 1 _ �wo A.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 /> Facility NameVy-Si 0 W -r <br /> Address: 1 ,n , `=`max --Ll U `6 City: \T y-l u��t Zip: C7� 9-7-( I <br /> Phone#:(1.6 01 ) `(o - 1319 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 07/31/08) 10 <br />