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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 /> ifif f!!f#!1f#iff#1fltflflflfaffflaffiif!!!f!!f!!lfffeaffifaafiflftlaaaf!#aftlfYlfaa!lifflfflalaaaRfafffafff <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 completed <br /> and returned. <br /> FACILITY NAME:City of Lodi Municipal Service Center <br /> FACILITY ADDRESS: 1331 S. Ham Lane Lodi CA 95242 <br /> TANK ID#39-0002313320133205 TANK SIZE: 2000 Gallon PREVIOUS TANK CONTENTS: Waste Oil <br /> SECTION 2-To be filled out by tank removal contractor. <br /> Tank Removal Contractor: ZIT/" 7;�IJV ?rls Ole /lie a <br /> Address: ?d a 0X .3 S ;;p City: / Zip: gra 5-'o <br /> Phone#: ( 0% ) .3 jl�9-6/ 7S Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor .J//YJ /�Di21�� B�� /•✓G• <br /> Address: & /30x .3 5 7 City: e67121 Zip: for/ <br /> Phone#: ( L 0I I _:36S- 45;17-:5" <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. T <br /> Name:X,I?—TnJ Ti /e�X_Title: CoA)T,feZoi< Signature: 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 Name: 4J.—C S T GOiQS 7r G Qy//�/YJE�T <br /> Address: /v2 Z E R City: T R L o G /C r�Zip: / 5�3&r0 <br /> Phone#:( ZO2) 6 93 7 -V <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 07/22/10) 9 <br />