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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone:(209) 3420 Fax: (209) -3433 <br /> UNDERGROUND STC GE TANK DISPOSITIONTRACKING RECOR <br /> rryerrwwH N�vT�VRtsvfv s+k MwYryyMtil`f waYlk#sW MMV ivrq <br /> SECTION 1 — SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with s site <br /> identification number, The Tank Tracking Sheet is to be returned to the Environmental Health Departrnent in of <br /> acceptance of the tank by the disposal or recycling facility, The permit holder is responsible for ensuring that Otis lborm is <br /> and returned, <br /> FACILI E: <br /> FACILITY A E : <br /> TANK ID 9- NA, TANK SIZE: PREVIOUS TANK CONTENT <br /> wwwwwwwwwww*www:wwwww wwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwww,rw�rwwwwwww�wa**mow#wawwww*t*:waw wwww <br /> SECTI <br /> ON 2-To be filled by tank removal contractor <br /> Tank Removal Contractor: <br /> AddrZip: <br /> Phone : I Date Tank Re <br /> wwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwww*wwwwwww:wwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwww#wwww wwww <br /> SECTION 3-To be filled by contractor"decontaminatingtank", <br /> Tank DecontaminationC <br /> Address: City. dip: <br /> Authorized representative of contractor certilyng through signatme below that the tarn has been decontaminated in an <br /> roanner as required by Cal EPA. <br /> N T Signature: <br /> wwwwwwwwwwawwwwwwwwwwwwwwwwwww* wwwwwwwwwwwwwwwwwwwwwwwwwwwww wwwwwwwwwwwwwwwxwwwwwwwwwwwwwww wwwww <br /> SECTION 4.To be signed and dated by an authorized rep to of the treatment,storage,or disposal facAity <br /> ng <br /> tank r piping. <br /> Facility N <br /> Address: Qi CS City. Zp: <br /> Phone# <br /> Date Tank Received: <br /> N Title: -Qignature. Date <br /> 1`3123046 (Rcviscd 1130112) <br />