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SAN JOAQUIN <br />--COUNTY-- <br />Environmental Health Department <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 — SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its <br />site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 <br />days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this <br />farm is completed and returned. <br />NAME TY -MV II'l (�QjjQjl I t lG <br />ADDRESS: 2Q5(i® S .Has►'I . I \W; I . <br />TANK ID #39 - CIS20 W TANK SIZE: 11 JU0 9c41 PREVIOUS TANK <br />CONTENTS: TUel G'il FIQGit CM Oil <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: City: Zi <br />Phone #: �) Date Tank Rem <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />City: <br />Phone #: <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />approved manner as required by Cal EPA. <br />Name: Title: Signature: <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 <br />Name: <br />Phone #: <br />Date Tank Received: <br />Name: Title: Signature: Date <br />9of10 <br />