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P <br /> ' HCl NED <br /> ENVIRONMENTAL HEALTH DEPAN'- EPIL I <br /> i 1 ii,En3 <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION K - 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 <br /> completed and returned. <br /> FACILITY NAME: c� <br /> FACILITY ADDRESS: S J �ra l�r� YtU <br /> TANK ID#39- 05-0 YP y y _.TANK SIZE: OO PREVIOUS TANK CONTENTS: / ADSL. <br /> 0,5— vs,4 S' <br /> OCR- <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Z7^ <br /> Tank Removal Contractor: ­P-19.0-42C h//n d�oe.y. T ce, 0 <br /> ,c a ®®�_ 1 �- <br /> Address:—&� �� /�` u 1�2fA CtrU UC'z,��9 �. City:_k�,tc20 !-, zip.---2-9 Ir <br /> Phone#:(;9) 7 ,�E�<7;96 Date Tank Removed: A60, - 1 ) <br /> SECTION 3-To be filled out by contractor"decontaminating tank": / <br /> Tank Decontamination Contractor: c_ y�,�r, x ct,"(c O h- _ <br /> Address:_z6 fe, w at.e.4 - 4--`` City: t Zip: �✓S.� t� <br /> Phone#:(.2 <br /> Authorized representative of contractor certifying through signature below that tZtankbeen ontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: 1°9-WK2Y Signatur �, Date—_1 'Dq <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: o t <br /> Address: City: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Name: Title: Signature: <br /> ********************************************************************************************************* <br /> EH 23 046 (Revised 07/31/09) to FIL <br /> E COPY <br />