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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 vWhin 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 I I <br /> FACILITY NAME {24 IC i rs 7L_ Lr{r.Gc�s �ci -__ Lit ' <br /> u,,Jtt: <br /> 1 <br /> FACILITY ADDRESS_ _ S N• ��V n ��r S fnG L-fCt;'n C�} <br /> TANK ID#39- TANK SIZE 1' `� PREVIOUS TANK CONTENTS <br /> SECTION 2 -To be filled out by tank removal contractor <br /> Tank Removal Contractor lrr)J_Ef tif?i► eA4L� �n(iln�,n nLr 6oA]<�GT'(/l cs �L-//G <br /> Address 6O1 r14 L,en�er Orlu-t— City Sdn) - 4-0 0- Zip 9'270 <br /> Phone# � Date Tank Removed <br /> SECTION 3-To be filled out by contractor "decontanunating 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 decontanunated 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 authorized representative of the treatment,storage,or disposal facility <br /> accepting tank and/or piping <br /> `k <br /> Facility Name ; <br /> Address City Zip <br /> IPhone# (� ) <br /> Date Tank Received <br /> Name Title Signature Date <br /> ' EH 23 046 (Revised 3115102) Page 10 <br />