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• <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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: Kit I Sa 2 M fn l c-41- cCr✓T9 2 <br /> FACILITY ADDRESS: 1777 06-sr YaCfMiT-C VE, H*,y1 cCA4 _ c' <br /> TANK ID#39- TANK SIZE: 90601ki PREVIOUS TANK CONTENTS: DIJESIEt. F'y C1, <br /> SECTION 2-To be filled out by tank removal contractor: L /Nr P4�k6 aJ'uK.¢a <br /> Tank Removal Contractor: rwr !r S"Iae121 0 R WT 9112 VI crz <br /> Address: 6• BOX oK I LH 7 City: ShAt R/EMor,) Zip: 'if .? <br /> Phone#: (9 ) �I�l ^ 8�7 Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank DecontaminationC_ <br /> Contractor: L r-4 f Wt 1,€2 <br /> Address: 191 0. ig 2 g b7 City: olul om C 1Tr Zip: <br /> Phone#:( /6 ) -11j " (o'f S,f <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: <br /> Address: City: Zip: <br /> Phone#: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 07/22/10) 9 <br />