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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 — SJC•Environmental*Health eDepartment's•Tank•Tracking*Sheet'shallkaccompany 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 <br /> and returned. is responsible for ensuring that this form is completed <br /> FACILITY NAME: aAx____ v <br /> FACILITY ADDRESS: , <br /> TANK ID#39- gS2 <br /> TANK SIZE: <br /> �PREVIOUS TANK CONTENTS: <br /> SECTION 2-To be filled out by tank removal contractor: <br /> 1 <br /> Tank Removal Contractor. J i w\- ]1:iO 1Z E �/� 1A)(f <br /> Address: <br /> City_ yOJ 1 Zip: 5Z5L / <br /> Phone#: f71�9 Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor �:aivK Tlioiapr ©lL /Aft <br /> Address: )C 3 S 7 <br /> City, .4-0 Jj l zip: 9 Ste] <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. <br /> NamelVA9718 7711614Pr Title: A)T,� <br /> ro tZ Signature: Date <br /> **#*******#****#***#*#**#*##*#********#***#***#*#********#********************#********#**************** <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: <� Sy��f� PIZO�LA P T C <br /> Address:) Fzy 506tH J1L_ n <br /> Phone#: `' qui <br /> 1 C1 CityPAW.Etr�("o i//zip: 957 <br /> Date Tank Received: <br /> Name: Title: <br /> Signature: Date <br /> EH 23 046 (Revised 8/1/11) 9 <br />