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i • <br /> ENVIRONMENTAL HEALTH DEPAR MMVED <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 OC ► I ' 203 . <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING FtbOWiNTAL HEALTH <br /> art*aaaaatra�tata�wtaaaata+aart*:raaatrraaa*rfaa+++�,tr�traa�r+air+t++tt*wa+k+�x++xiwr�art+:+*rt+r*tr*�, ��T/�FRVICES <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:_ L2 <br /> FACILITY ADDRESS: �✓ / k! <br /> TANK ID#39-QS D(061_TANK SIZE: tA2 PREVIOUS TANK CONTENTS: <br /> **-7* t*t * tr*ter* ****x ** <br /> SECTION 2-To be filled out <br /> -b-y tank removal contractor. <br /> Tank Removal Contractor nn <br /> Address: ��(j CJ Z City: �/J/ Zip: <br /> Phone#:(,Q/- / Z- > ��Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination/Contractor. /. / / i <br /> Address: Po (312>< :f ,�2 City: Z-6 12 1 zip: .9 <br /> Phone#:(2—(J-- <br /> Authorized representative of contractor certifying through signature below that t4tanks beendecontaminated in an approved <br /> manner as required by Cal E <br /> Nam Title: �l►��� CIQ�Sigr►atuto <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tank and/or <br /> Tpiping. n <br /> Facility Name: N/ //2� l L �� ��O19�/G-7Sy <br /> Address: ./�©Qd ! 7 (.,:/ C5 --� P&,14, City: `C-0d.9< Zip: <br /> Phone M(C116 S <br /> Date Tank Receive: <br /> Name 144 � (y (c i ture: 7 l <br /> oL7 7- <br /> 77g <br /> EH 23 046 (Revised 8/1/11) 9 <br /> I <br />