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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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 v ithin 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 NAMErGt <br /> FACILITY ADDRESS �( Q N _ 1- v n fir <br /> ' TANK ID #39- TANK SIZE PREVIOUS TANK CONTENTS <br /> SECTION 2 -To be filled out by tank removal contractor r! <br /> Tank Removal Contractor Enujrn&meniml <br /> ' Address 3"01 Par11_ c,en ler City SAAX_- 4-4 a-- Zip a-,7 <br /> Phone# ( � ) 66 7-7-306, Date Tank Removed <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 /> SECTION 4 -To be signed and dated by an authorised 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 3/15/02) Page 10 <br /> 1 <br />