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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD SECTION 1—SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. T FACILITY NAME: I-ZC-4J 1) / �U / FACIIITY ADDRESS: / l� ✓V C✓YL/�©/C'N/s� S TANK ID#39 TANK SIZE: �C�C� PREVIOUS TANK CONTENTS: t!!#Yr#!fr!####kWi###Wi#wi##rtwwf####iwWW#f##WWWW#i#s#}W##tWWwif##iWW#wi###iww###WtW4#r}Wi#####tWWWrwWW!#yki SECTION 2-To be filled out by tank removal contractor: Tank Removal Contra–cttor. Address: S / �(/ L7�C/V�//��/ �O- City: / zip: Phone#:( 2 0%) 3,6 OC',6^i 7S Date Tank Removed: YYW}fs!lWWYWwY###sk}###w#sYw###iWwwwrt##st}i##;ss}}k#sW####WW###t#ktY}}rt#rtw##srW Wyk##kW#wrt##stWww#ff#rr#i#wW SECTION 3-To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: /� �,;!52 Address-."3 5- 7 A.). l2j�, City:/ Zip: Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. p Name:�/�/�� tJ zl /Ll Y Title:C,-2,)l Signatur L`- ate i#kksrilfiiwi#!irt#fi##WwtWW##i#ttwwirt#rtW}W#####Ww##WWWY4#iWW### - #irt Yww}IIsi i#tYi# YWwir}###rtitwW}##k SECTION 4-To be signed and dated by an authorized representative of the tre tment,storage,or disposal facility accepting tank and/or piping. FacilityName:�� City: (2/d%/F Zip: Phone#: Date Tank Received: Name: Title: Signature: Date i}striir}Yk#si#irfrwY}##Ww#}iisW}#;sYWw####W}Y!#Ww#tW#iissiw}##s#r#Y##siiW##tWW}#fi#itYYWWW}Wi##kWWrWRiss EH 23 046 (Revised 3/15/02) Page 10