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SAN JOAQUIN COUN r-" <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />f Wjj- f7KAMII Wiffl) EMW TIAIVrAn F, 1; 1 j k� — . 1111?1�'Tll <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: <br />FACILITY ADDRESS: <br />TANK ID #39 - B r TANK SIZE: jh( )084) PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be fined out by tank removal contractor: <br />Tank Removal Contractor: <br />N <br />,--I- : �� <br />IrV V . zip <br />Address: S�, 4k2n,_ City: <br />Phone #: Date Tank Removed: <br />SECTION 3 - To be filled out by contraIv <br />"decontaminating tank7': <br />u <br />Tank Decontamination Contractor:_ - <br />Address:_ <br />Phone #-. <br />City:- Zip: <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. 0- Lffl� 40- /_ kl-Q - <br />Address: 4oA en) <br />--737Z) <br />Phone It: <br />Rd. city Zip: Ylix(a <br />Date Tank Received: <br />Name: Title: Signature: Date <br />EH 23 046 (Revised 10/16/03) Page 11 <br />