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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 /> 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: St. Joseph's Medical Center <br /> FACILITY ADDRESS: 1909 Cerretary Lane, Stockton, CA <br /> TANK ID#39- TANK SIZE: PREVIOUS TANK CONTENTS: Diesel <br /> x������x�rx,r:r:��������r+�+��x��xxxe,t:r,t:t:t���������+�+r.������+++�+�xx���+�++����e::tw��+����e��:r�+���+r��:♦ <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Elite IV Contractors <br /> Address: 2535 Wigwam Drive city. Stockton Zip: CA <br /> Phone#: 2( 09 ) 461-6337 Date Tank Removed: NA <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: Elite IV Contractors <br /> Address: 2535 Wigwam Drive City: Stockton Zip: CA <br /> Phone#: 2( O9 ) 461-6337 <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 /> Name: Title: Signature: Date <br /> :::�+���+�+axe....•:�:r��:x��x����+�x+x�.������x������++«:r:r������������z�����������r•+:�:����xx+*e*r�xr.�r, - <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: NA - No piping being removed <br /> Address: City: Zip: <br /> Phone#: U <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 8/1/1 l) 9 <br />