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05/30/2003 16:36 209468343' FIFTH FLOOR PAGE 10 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACkING RECORD <br /> ww#ssswx#wss;wwwisii'wwwisiiwwwwssimwww#stsx7wwlhltszsRwMwktxiwwwzxwMwlkxts*wok#sxiwwkeK*ssxwMwkzssyiww#iiywikksi+N <br /> SECTION 1-SJC Environmental Health Depattrnent'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: 7 ' �e V c vt1 540i2e- ZZ3 7 - 159 7 Ca <br /> FACILITY ADDRESS: l39 ct YU. "A i w M,AAe.0 A CA <br /> TANK ID#39-5 51D 32 I TANK SIZE: 1 O,UU O PREVIOUS TANK CONTENTS:_C <br /> s*wwwwsssiwwwws*sswwww#**sssww*ww###sssiwwwww*#siiwwwwww#issxwww*#s*www**ssxwww#s#ssxx*ww*wxix**ww**ixi*w*# <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: G(ACteo2 G-VcJtu2oNMew�A( 5cau�CC � �rvC. <br /> Address: L1c111, ZygStll t��. �u� �e t4 City: IV(uA,I CC,! WA Zip; ct18Z 7 <br /> Phone#: 4( t5 ) 355- Za 7-Co Date Tank Removed: <br /> wwssiswwww#s#wxwwww##sisxwwwws#:tisxsxxw+www*s#iiiiix**ww*s*ssws*ww»s*ss*www*#ssiwwwwwsxssxwxwww*ssxs**www#*s <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor; M P G vu t %ZRYP v�u e,n1'� 1 <br /> Address; 3400 MAyUO%Z 15hceAr City: 8 key &. rtk& Zip: 233oa <br /> Phone#: (.s( 6( ) 313 • 11 S l <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 /> Name: Title; Signature: Date <br /> *sssiswwws*ssswwww#s#sixi*wwww*sxssxswswwwww#wssxssiss*wwww#s#ssxwwww#sssxwwww#ssssswwwww**ssssswwww##*ssii <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: <br /> Address:_ 1610 LL)PS+ 11E" 5+. City: L OVQi SeWe.� Zip: <br /> Phone#:( ) <br /> Date Tank Received: <br /> Naive: Title: Signature: Date <br /> www#is:siwww#ssssiwwww#sssssss**www**sisissssixrwww**#s#sssrwsww**sssssr,www#ssssswwwww**.ssissx*wwsssisss <br /> EH 23 046 (Revised 3/15/02) Page,10 <br />