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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:L-// +1 m( f v tw c rr y l2 k r)w I M Sl tC <br /> FACILITY ADDRESS: 'L2b U%7,S LVv TYtIL <br /> TANK ID#39-DTANK SIZE: PREVIOUS TANK CONTENTS: Lw�.Wnoc.c9r.._ <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: A0�t�6. <br /> Address:_-l7i F�o r-3 Y !q l(p CI, City: L4L U,_ Zip: Q S;20 <br /> Phone#: (S3Q 1 S[j -(a Q3o Date Tank Removed: <br /> *#***********+*+#+#*****************+++****************+*+**+***********+*+***#*********+****#*********+ <br /> SECTION 3-To be filled out by contractor"decontaminating tank`": <br /> Tank Decontamination Contractor: � �n.n�. rbc,\tx�_�_ (LrA e; .CZ:aL� <br /> Address, tCh t7C )c °711,8 City:. , Zip: qsS o04 <br /> Phone#: ( $-j0 ) 931 -&i3q <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 /> 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: rs c&A T (Z fj (tv�V�T <br /> Address: IZZ, I S . j_Lt3 akr City:j&y'IACj, Zip: 913�S <br /> Phone#:(209 ) 101,I' - Ct 37 8 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 07/22/10) 9 <br />