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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Far: (209)468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ..........................................................1...1...HL.................................... <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: Xu J 4- L - <br /> FACILITY ADDRESS: <br /> TANK ID a39- aICZ TANK SIZE: 12, D DO _PREVIOUS TANK CONTENTS: �1 ' <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: p )_ <br /> Address:_ A� Y 1 �Tt &V___City: <br /> Phone#: �,�"��i D (te_Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor. p I l - <br /> Address:—T`{( L b(p A,,-X 1� �� C .2:4Cil Zip: 9 Sd=l ) <br /> Phone#: Qz)9 ) 9 3,� - n v ep <br /> Authorized representative of contractor certifying through signature below that the tank has been deccntarninated in an approved <br /> manner a required by rCal EPA. _ <br /> Name: _Title:497, J C Signature: Dat&L <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: LR-J-)y-p C- - <br /> Address:-) C� �� :Jj ry,,C �� City A--" Zip:0, � <br /> Phone#:(� ) ! L-. 9, 5-&s <br /> Date Tank Received: 3 Al <br /> Name: I Title: Signature: Date <br /> EH 23 046 (Revised 10/30/12) 9 <br />