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ENVIRONMENTAL HEAL111 DEPARTMENT <br /> SA N JOAQM COUNTY <br /> TeIephDne: (209)468-34Z0 Fax: (209)468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - SJC Environmental Health DeparlmerWs Tank Trucking Sheet shall a=mpany each tank affixed with i g Me <br /> Idarytflcndnn number. The Tank Tracking Sheaf IA to be retumea to the Enwtmnm,ental Hnelth Department within-,V_vg of <br /> Viomptorice of the tank by the disposal or mqyd1rq facility. Tho permit hotdsw is responsible 1br anawft that this corm In carrpWad <br /> and raturned. <br /> FACTLI-FY NAMF- <br /> FACIUTYADDRESS: B. L-d:x t-)643,r, *A-0,4 M Lo&�P�F", Coe. 4PI M,=-VBkD <br /> TANK 10*39- -1 —_TANK SZIFj_2�La REIAQUS TANK CONTENT-S7. Gpw--?00LI"M <br /> SECTION 2-To ba filted out by tank removal contractor <br /> Tank Removal <br /> Address: Q,74--t 18P,1 rA?=fjp!- CX' Cly ZI <br /> Phone!k DMB Tank Rmcved: <br /> SECTION 3-To he I'Mad out by cuntractar"decoritarrifnatfnig tank": <br /> Tank Deconturrikia5cin Cont=1or. <br /> Addraszi: 4 �- <br /> 4Lo?,JZDP-A b- .V Z-, car.e:� l zip: 90� <br /> Auttwxked representaMm of cont-iclor cwtifyl ng fliough 91gnmWra below IhA the tank h ae bw d ihcrrtarnbnsled 7n an wpruvm <br /> manner as mqLqred by Cal EPA. <br /> N=a:AN14 <br /> 2*a*At*Q************ <br /> SECT"4-To be stgned 9M datad by an authoolzed ropmwnWvw of the natinent;storage,or dbspoaal WRY <br /> accelAng tank andfor p#M. <br /> Facility Name. -)�qV421Z- glozG --L&a� <br /> Addr <br /> phone <br /> Date Tank Received: J 7 �-Q <br /> L <br /> Name; elza <br /> EH23W (Revised 071221I0) <br />