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ENVIRONMENTAL HEALTH DEPAP <br /> SAN JOAUIN COUNTY �69kED <br /> Telephone: (209)465-3420 Fax: (209)463-3433oC 12 • 2013 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING <br /> **#*1tr*#*t* E <br /> NTAL HEALTH <br /> SECTION 9 - SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tali-�a�t�etl'F' ite <br /> identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 39 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 �KSIZ�p- PREVIOUS TANK CONTENTS: 7 <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor /G Lyl/ <br /> Address:_-.2 0 6_e_ 3 -�L 2 City: / Zip: - <br /> Phone M ,2 2- 9 Date Tank Removed: 9_ o L3 <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: / �1oly`2 lC / n _ <br /> Address: 2,Xf S city:�l Zip: <br /> Phone#: 429 _2 , <br /> Authorized representative of contractor certifying through signature below that the tank s been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Nam _ Title: ®��� StSre:n Date --L'7'� <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: 2'Z-El( 51S <br /> Address: Z ac C ) City:_ --Zip:_. <br /> Phone# <br /> Date Tank'Receiv cJ � � ^ <br /> o / <br /> Name. tte: 2 �/(2JSignature tel- <br /> EH 23 046 (Revised 8/1/11) 9 <br />