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ENVIRONMENTAL HEALTH DEPARTMENT, <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)4GS-3420. Fal: (20,4)4GF-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> YA AY'iYA' Y'i'AM"A'A''A'ARAk'i'i'A'k Y"A'iY'A'FY.'iAA'Ai'Ai'AA' '—''i'xYt't'.AA'Y iwi't­Ai'A'r.'A'tiA'YiY i'tY'i'tk4'iY'iY'l'iAA ttot Yi-'t i'i N Y i Y•A'i'A'�kA <br /> SECTION 7 - 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 34 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 /> FAC IL ITY NAME: C'(_q pwm n _-- <br /> FACILFFYADDRESS: s-0 NA), \ �1{o co Rd T•��l C��_j <br /> 0157, a� <br /> TANK l x#39- " TANK S IZE: 2 21\ PREVIOUS TANK CONTENTS: <br /> 'itXTt•'iSTT)C)CS%T'FTT"�CTTYCY'iTT:F'C�:'1C'TC�'ICTTJC%]C'.�'C J%)C ICCTT)C�[T'+C%T�C'F•iK C i[�:CFT.T')f%Jl'TQC'F'�C"IC:['%JY'iCi[]f%:C%�C'iC'%C:C'iCTi:%�C'%fT ICY<lC tc T'FTT'T%'T'!CT?' <br /> SECTION 2-To be filled out by tank removal contractor: / T <br /> Tank Removal Contractor: kJP,,AAV (� <br /> Address: Dn N 3 City: ( l Zip: <br /> Phone#: _ Date Tank Removed: -1a"\' <br /> %x'%F]C'F'X%S YC K%TT T%7C%iCT%%],t iC%T%%%%%%T%%'T% lC T%T"T r1':C%T•T.)C1C:F:EAG%*%YC%%%�%7[%%F C�G1C:C x 7C%%'T'�CT'%%X%%%%TSYS%%TCr T YF%C'+%'.0%:S�C% <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamiinatlon Contractor: Xp" 1 J1 G — <br /> Address: V,96 r 41 rr"Am 81\)P� City: &Y r-den of Zip: et zye -- <br /> Phone#: `t)o --- <br /> Authorized representative of contractor certifying through signature belowthat the tank has I3 en decontai nated In an approved <br /> manner as required by Cal EPA. <br /> Name: �F W.e4 Ttle: Of i&A& Signature: Date-JL <br /> SECTION <br /> f%^C%%ifY:<•K:C'CX%^C:CY]f:rY[ifX%'iCXX:[YT`.c%ifT':F Yf if`f`CYC'if^f'.C'F:C%>f'1f:f:ClC�CX'IC:fX%`:)f'iC7C•if)f:f•iC)Ctf:<:CX:C%%X'XTSFX^C%x'T':C%YCF*t']f1C:t'C%]f:<if:f:<::'iC]t"lf:C if:F YYC i <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: ogzo iI&a 'p )_ay �V )J <br /> Address: ), i2Gr S r_n 26od City: . (0Q/_MGe Zip: q-1� j <br /> Phone#:( qZ } I/y 6n- a[fq) _ <br /> Date Tank Received: __ ? <br /> Name: Ttle: Signature: Date <br />