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0 <br />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 />************************************************************************************************ ********** <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 <br />completed and returned. <br />FACILITY <br />FACILITY <br />Z5' <br />L <br />TANK ID #39 - TANK SIZE: S ® PREVIOUS TANK <br />GO.�t9Ci1 � <br />##############################WW#####WWW####WWW####WW################# <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal <br />City: Z00% <br />Phone #: Date Tank <br />-0 <br />SECTION 3 - To be filled out by contractor <br />"decontaminating tank": <br />Tank Decontamination Contractor: ac. --I <br />i <br />Address: [�(� 6CX 3 5;;7 City: <br />Phone #: <br />CC— / <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />manner as required by Cal EPA. <br />Name1. 1 &7Zj /4-441,:5 Title: Signature: Date <br />W###W######**#####W#####***####*W####**#W###W#W####*####WW####W#W#W#**#WW##WW#*#WW*#W#*#W**#W# <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: /t / <br />Address:_ S. ifaST city:s1AJ72e�f zip: <br />Phone #: (% 0) % 9�1 - o-) _ C) f-- <br />Date <br />/ <br />Date Tank <br />****WW#W###W*######W****##W*#W##WW*****###WWW***W#WWW###########W####**#WW#**#W##*#W###W#W*# <br />EH 23 046 (Revised 07/31/08) 10 <br />