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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 /> 4##tt#4####444*4#######4########*######*#######******#*#*************#*********#*****#*#4**#*############## <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: <br /> TANK ID#39- TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: City: Zip: <br /> Phone#: ( ) Date Tank Removed: <br /> ******************************************************************************************************** <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <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 /> Name: Title: 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: <br /> Address: City: Zip: <br /> Phone#: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/30/12) 9 <br />