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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUM COUNTY <br /> Telephone: (209)468-3420 Fhx: (209)468-343.3 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - SJC EmAronmenlol health Department's Tank Tracking Sheet shed each tank afted with its silo <br /> iderfliffeaffan number. The Tank Tracking Sheet is to be returned to ft Env=1=1014aalth Department*Mn_3j_cava of <br /> acceptance of the took by the disposal or recyclkq facility. The partnit hofder is responslWa fur artsurkV that ft form is ampkAud <br /> and returned. <br /> FAC-11.rry NAME: P---P <br /> FACUTYADDRESS- 12'!)F;l 5. C4e-. <br /> TANK ID X9- TANK SIZE: J;&C06- PREVIOUS TAW CONTEWS: Gm--001-04S <br /> SEC770M 2-To be Red out by tank removal cGntr2ctor. <br /> Tank Ramoval Contractor Gt�r1'S' t r1 <br /> Address: 91 r J--.--of y. pl-i-M*-, zip, <br /> g9=1&t& <br /> Phone 9: 1 ZF.T'l. -15;45p5 —Data Tank Removed: <br /> SECT1014 3-To ba tilted out by contmotcw"decontamlinaffnq tank": <br /> TanR Decontamination Conh=tur. Is 'S�r'-V I <br /> Addr=s: 4 e- <br /> 4Lo r4-D R A fDl-\l 1 Ct,, -RZ G- zip: <br /> Phone*(310 <br /> Authorized represeriWm of contractor certifying through signature below that the tank has been dacontamlne(ed in an approved <br /> manner as required try EPA.Cal EP <br /> N=e.AN'4 'Sa.0'r7- <br /> SECTHoN 4-To Do signed and dated by an Autharfted r9presentatwo of storage,or d1spcsaf fociffity <br /> =44ng tank and/or piping. <br /> Facility Name�D()w- 'tqere <br /> Addre8s:171-Dr) I t� - V Q- oz) <br /> P q25) 4q,** <br /> hone 41*C , <br /> Date Tank Revoked' <br /> EU23046 (Revised 0MV10) 9 <br />