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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 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: <br />FACILITY ADDRESS: / a <br />TANK ID #39 - D 2- (o I TANK SIZE: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: <br />REVIOUS TANK CONTENTS: <br />Phone #: ( ) Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />City: <br />Zip: <br />Tank Decontamination Contractor: <br />Address: City: Zip: <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 />Na <br />Signature: <br />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: <br />Address: <br />Phone #: ( )_ <br />Date Tank Received: <br />Name: Title: <br />EH 23 046 (Revised 8/1/11) 9 <br />City: Zip: <br />Signature: Date <br />