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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 /> 1Rf R♦♦ffRffi♦RfififfRfRffflfR♦fffffifflf♦R1fff4fiftftftff RRlRf♦if ifff tRlRtRiff Rfif tff itfRRf fff ifltffffiflRR <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: fff-yOeNf:> <br /> FACILITY ADDRESS: �S �• 1�0���E �•�/E . L�+t'1-41�OP, GI►� 0533'L�> <br /> TANK ID#39- 2 TANK SIZE: 0�COOS PREVIOUS TANK CONTENTS: �1jOi` �tNE <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: G >R-yowl NV C <br /> Address: CL-74--7 Sl6424�A G"r'• -_Wi'r-- J City: D1j;3V'L.1N zip: 1 45 <br /> Phone#: (912-5.' 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 authorized 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 07/22/10) q <br />