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05/30/2003 16:36 20946834'') FIFTH FLOOR PAGE 10 <br /> SAN JOAQUIN COUNTY <br /> ENVIROYMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ww#*##w#M#ss#w#Y#s#1wYw!*sY*MN#ssi#ww#***!s#wwM!lssY*#M#aslsww*!*www#alsw»#*aswww*!#!!lwww*ssswww#ssxw#*aa# <br /> SECTION 1-SJC Environmental Hcalth 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 Departmentwithin 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 - t le o c vV 540i2r_ ZZ-67 - 155-ICo <br /> FACILITY ADDRESS: (act ct VI J. t'u1 A i rU M A w{--c-A CA <br /> TANK ID#39-_t TANK SIZE: 10,000 PREVIOUS TANK CONTENTS:—C A so I ru t' <br /> s*w*ww*##!!w#M##iYxa#MM#+ks#!sw*w+�***!#slwwwMw*#*s##xwwMwMslsswww***xwwMw#lswwww*x**ss*www*#sY!**wws*aeYsww** <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: G(A C.l e Z L-_7 L t t2 e N 1%l e W A-M S e tZ u%CC i 'tw G <br /> Address: L1Lltto Z�gStll t�J, �u� �e City: Muk, �WA Zip: cie?"? <br /> Phone#: y( 2S ) 35S- ZS?-Co Date Tank Removed: <br /> *#sssswwwwMi*x#w+N ww**s!*#Mwww*#*sax*xswwwMw.Y*s!!!#*wkwwk**ss#iwwwM***swWNlt*#s#1ktNw**i#*sxK�eMMkks#ayywW+kM#*: <br /> SECTION 3 -To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: M;) L vu U t tZ0vV v A e, <br /> Address: 3 100 MAyU0%2 154 gce' City: 8Ake!Z6Agk& Zip: g330a <br /> Phone#' (s( o( ) 3S3 - t L 51 <br /> Authorized representative of contractor terrifying 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 /> *slseswww##!ss#www*s*sa*Y#wwwM#lsss**ws#wwww****!lsssswww*w***ssxwww**ssx#wwwM#slsYaxw*ww**#sss!#www*##is** <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 /> FacilityName: C 0_05b�? °F 00e-11., Co v%3 <br /> Address:_ l Ls I O U-)e-S+ l`l` % 5+, City:j„pv-%)T Zip: <br /> Phone#: ( , <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> #aw!#*sslwwa*#ssslxw#M#slxssss**,NMw*#llssssas#ygrww wile!*s*sssr l,�w*d*s!!»srwMM*s#slsy##w M***sslss*N ww�ellssss <br /> r <br /> EH 23 046 (Revised 3/15/02) Page,to <br />