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ENVIRONMENTAL TH DEPARTMENT <br /> SAN JOAUIN 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 Slays 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: Fp,AFA- <br /> FACILITY ADDRESS: <br /> TANK ID#39- A TANK SIZE: '0� PREVIOUS TANK CONTENTS: JNVWVVA / <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: APIS <br /> Address: 34At) Mwot ST- City: 6* sIef C,,t-9 Zip: 13 709 <br /> Phone#:( 6G� ) 0�" Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor. n� <br /> Address: 3` OU T- City: /)A K—r*W Ft f,1 Zip: q1100 <br /> Phone#:( A( ) 3O 3- 9Ste" <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 8/1/11) 9 <br />