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ENVIRONMENTAL HEALTH <br /> SAN JOAQUIN COUNTY <br /> 4APJ <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> rrararrxxxaxaxaataattatx,ar.arrrt.rta+tr+t+,trtt+t++++ttattt+xtrt++at+ttt++t++<at+tt+rrr+ttt+r+++rre+e;tratrtrxrtr <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 939 WML. TANK SIZE: -5 ->& PREVIOUS TANK CONT�E,cNTS: _f s <br /> SECTION 2-To be filled out <br /> -byy-tank removal <br /> contractor: <br /> Tank Removal Contractor. n _ <br /> Address: /?® 6 C, � �� City:_ Z-0 Z Zip: <br /> Phone#:(2,t2i_) 2 / Date Tank Removed: <br /> SECTION 3-To be filled out by contra-c-t-orr"de contaminating tank": <br /> Tank Decontamination Contractor. <br /> Address: �aQC� S City:_ Z-&I l Zip: <br /> Phone#:L2—q9 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal E/ <br /> Nam e/� ' �r��1 Title:� l✓t�C`�/(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:- a tJt°� 6 7���t�� �c�J��. City: 20422d' Zip: <br /> Phone#:( <br /> Pater Tank Received: <br /> Name: Titles Signature: Date <br /> EH 23 046 (Revised 8/1/11) 9 F <br />