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_SAN JOAQUIN i <br /> ENVIRONMENTAL HEALTH <br /> FNT <br /> I COUNTY <br /> Telephone: (209)46$-3420 Fate: (209) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRAGKING RECORD <br /> **#-kkrt*k'i4*###R#�#xY4'k'0"R'A9`H'kkX`R'1°hwR»R#Rw kk#**w*tfYkkRw»khyekhrt»#er»R 2#'k#R#+R##.t(L»*#*iNRaast#sR#*#dwkkwtr+dwaa <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 complet <br /> and returned. - ®A <br /> FACILITY NAME: `� Ti �� J 1 Vt�� W A- Y �`'k G <br /> FACILITY ADDRESS: 'A GC �� Y�''n� <br /> TANK ID#39- TANK SIZE:A) ®U PREVIOUS TANK CONTENTS: ` 0( <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contracto : '` t�vtY�tn�'vlPl� �� <br /> Address: <br /> G °�. IY�. City: <JGtcretn'tt t> G Zip:_ <br /> Phone#: g( i6 . ) 563 44-76 Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": I <br /> Tank Decontamination Contractor: �?� Pi71�t�►�th L - <br /> j,.(R1 i Address: Colo _� !i l df cf City' s z r, Zip: <br /> 1t '• <br /> Phone#: moi( j > - 72-70 <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 /> 7 <br /> Phone#: <br /> i <br /> Date Tank Received: <br /> i <br /> Name: <br /> Title. Signature: Date <br /> l. <br /> EH23 046 (Revised 10 3WI'-) 9 <br />