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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Far: (209) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SEC'T'ION 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 <br /> completed and returned. <br /> FACILITY NAN E:_ [ <br /> FACILITY ADDRESS: _:,_5 <br /> TANK ID 09- TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SECTION 2-To be filled out by tank removal contractor: <br /> t <br /> Tank Removal Contractor: <br /> _ Zip: <br /> Address: � `CCity: . <br /> Phone#:( } �� ` Date Tank Removed: <br /> SECTION 3-To be Filled out by contractor,"decontaminating tank": <br /> Tank Decontamination Contractor: �J W u C�L�C, <br /> Address: City: Y ," d-._ 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 /> Title: Date <br /> c Sibnature: <br /> Name:>�Cw <br /> — -- <br /> :k:k*A::k�k#�k-k*:K:K�K�k�:***=k#��k:kW�#�:***'k*#*=k:k*'K*=K:k:k*:F*�I-**�'�Y•�k=K:k:k:k**-k#�*�k*-k�k:k:k��k�k�k=k=k�k��W�>kd::k:k:k=k**k�k:k*'K i::k?::::k:k K**-kk k;:k:i:-k�: <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: a—i° <br /> Address:_ <br /> City. c/r r t�3 Zip: <br /> d t <br /> Phone#: <br /> Date Tank Received:— <br /> Name: <br /> eceived:Name: <br /> Title: Signature:_ Date <br /> EH 23 046 (Revised 07/31/09) 10 <br />