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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*##+***w**rt#**#srtaws**rt#*#+*#w+##w*rt#wsrtww+#ww*+w**#w*rt#w#s*rtsrtrtw#**w+rt#rt*##ss**rt#s*#ws*****#rt*##s»wwsrt#s## <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 />FACILHYNAME: <br />FACILITY <br />TANK ID #39 - TANK SIZE: OO PREVIOUS TANK CONTENTS: <br />###################W#W#rtrt##*rtw**#rt#*#rt***##rt****#**#*******#*##*rt##*######s#############M##########rt»###rt## <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: />. ? 2 /,1d„N, jCe a_,, N_"'` t <br />Address (6 City: e Hca I1 <br />Phone #: (;) ,� 9� C -2f, Date Tank Removed: <br />Zip: ( ger. <br />rtw#*##ss###s###**##srt#wss*#rtrt»w*#rtrt*+#sw+*#w#ss#+s##ss*##s##rts##w***rtsrt###**#s*#w»*ws##ws##rts##w*w#rt#rt#ssrt# <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination <br />l� <br />Address: xe <br />. City: <br />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 by Cal EPA. <br />rtrt#*s#*s#+##w+###rt###***w+###s*###rt##w*###s*#wws###srt##+**ww+*#wss##w+rt#w*s#w+*#s#*#w*wws*sssss#w##»#rt#ww*# <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: 9 ,� -� t <br />I �io <br />Address: :. City: e4 F P/Zip: �.�3 — <br />Phone #: <br />Date Tank <br />EH 23 046 (Revised 07/31/09) 10 <br />