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0 <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 /> r#frrraf-f#fffffra#f+r+aara aa#r+ira#attr+afa#+raraaa+#aiiaaa+a+awr+a++aaaraaaa++a+a++raar+a+aaxtxrxtiaia+xrr <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: _z�? <br /> FACILITY ADDRESS: of C/6�,55 Al /7 W V ST 5 52- 3 7 <br /> mil <br /> TANK ID#39- TANK SIZE: PREVIOUS TANK CONTENTS: -l G <br /> SECTION 2-To be filled out by tank rem—ovacontractor <br /> coontracto /� <br /> Tank Removal Contractor:2 -7 //�7`62,4��01Z > /� ' <br /> Address: /?d d ?C 3 : �_ City: —!J/J zip:�� � <br /> Phone#:(2a C/ 2— / 5�k f / Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor, /,�/ // 10WI - Ole—', /-'✓e <br /> Address: I? (312 City: Zip; <br /> Phone#: <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required bey C(al EPA. e <br /> Nam sz�///�dZ //3°fJG Title: ®tJ/-�(-"�C7M,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. �1n <br /> Facility Name: NL / Z�+� 2/7s" <br /> l s"S,6 ��OP/C,(C 7�5' <br /> 2_U 049 r S .�`,`� <br /> Address `�� d �c�.�C/. City: E �J � Zip: <br /> Phone*(216) ! E S�� /L <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 8/1/11) 9 <br />