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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNT' <br /> Telephone: (209)468-3420 F:rx: (209) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> A**Ak'k E-k*R}**A*k*kYfT1ld'RRR*khW W W*W W h*W kR W RkM!*Wf##Wh WR W WRFfh#rtM#kR*F.l+RkkdtA#MR+*/t*##fFM#kY*HN#k***Rdxx W mx <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 complethd <br /> and returned. L /{►j� `- .} <br /> FACILITY NAME: `, <br /> FACILITY ADDRESS: rcir C . <br /> TANK ID#39- TANK SIZE: `V �V PREVIOUS TANK CONTENTS:JI t -or 'Kf(02A6 <br /> SECTION 2-To be filled out by tank removal contractor:: <br /> Tank Removal Contract% : vt ror mvell61' <br /> Address �tY"t✓ fit' ° ✓� City: ;J�iCt"An1�r� C Zip: lav <br /> Phone#:( 4 ), 563 776 Date Tank Removed: V/ 3 <br /> ,r*,+��***�,�*w*,rte*���r�r*�:YvrY;xrr�:rw,r�r�r***w��,�*•xv**,e**v,r*,��r�**,�*,r***,rte*x•,�*mow**�**�******�*�**t**R*****�****� <br /> SECTION 3-To be filled out by contractor"decon <br /> taminating tank": <br /> Tank Decontamination Contractor: .` " ' .f✓ yl,roiiM-Q,yt 11C <br /> 5e0Y!F-,>Address: ala :5L e-®-e 61 c.Q- City: Zip: <br /> 3� <br /> !r;7 Phoned:( j� ) - 7 2 2 0 <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 <br /> ate__SECTION k-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 /> - r <br /> Phone <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/30/12) 9 <br />