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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 /> ....................................................... ........I.............. ......I..................... <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: �y L <br /> FACILITY ADDRESS: Cf 2, <br /> TANK ID#39-018 I kQ3 TANK SIZE: 12, O DO PREVIOUS TANK CONTENTS: <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor. <Z111 <br /> n <br /> Address: ovj! �7 G !'H` ---Cy: Zip:_ <br /> Phone#: d Rc---D!-2 D (19 Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor._ p� �1 ��n� � C- Q C <br /> Address:" �l l^�/ 1i S Kl� City. Zip: 1'�c� <br /> Phone#:(�� ) 3v� n �p - <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner quired by Ca!EPA. <br /> Name: Title: Signature: Date _ - 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: �l / <br /> Address: �G� �C]j - City. O Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Name` . t •y'•�11 <br /> Title: �,Si,�1���,•c'�lz�9nature: �J�Date��� t 1 <br /> EH 23 046 (Revised 10/3(1112) 9 <br />