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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 /> .........N ..........................••.....I...........orf......=..Ntfl.���t�l�MtMi�NMf�1w�� <br /> SECTION 1 - SJC Environmental Heahn Departments Tank Trackuig Sheet shall accompany each tank affixed with its Bite <br /> identification number The Tank Tracking Sheet is to be returned to the Environmental Health Department Jig 30 days of <br /> acceptance of the tank by the disposal or tecyding faukty. The permit holder is responsible for ensuring that thus form is completed <br /> and retumed. /' <br /> FACILITY NAME d'Y 0 G br`A <br /> ig t. � 10 <br /> FACILITY ADDRESS: 42-0 t4)rl,is C_r2r.TttR Cr. Wir....y�,( y'+. e .- <br /> TANK IDAi. TANK SIZE. PREVIOUS TANK CONTENTS: <br /> f Rfliiiii'hilifs NiffafRfiiilii+ififiiiiiNf#k#iif\if#i#lrifffiffi#Niiif}kiiAi}fRfifiiif#R+ffiiliiiifffffi <br /> SECTION 2-To be fitted out by tank removal contractor: <br /> Tank Removal Contractor, ,.tet <br /> Address. ?.lav 6: 1 <br /> . :1. it b ___ <br /> � ,_ C1y, t u'- Zip. Q lIO-Qtf <br /> Phones:+.S`�Q I Z71% -to (C'j'./-( Date Tarx Removal: JlrR .S. I <br /> +1fiFlfifitiif4iif ffitilf Yfi#lftli4ifift)fif)ffttliifi#fl+f}t#i#ttfiiftitlSiii#i#fi#i###iii11#iR4lfiiiM <br /> SECTION d-To be filled out by contractor"decontaminating tank" <br /> Tank Decontamination ContraCtti .. rV. ;j3 r tazj`l r.1l nC� rQ_,�cr: <br /> Address: to, -)I(.i3 City-,�SJd}ese_.�Zip: �O� <br /> Phones:l .1404q <br /> Autnonaeo representative or coteractor certifying through signature below that the has bee nlamnated In an approved <br /> manner as required kly al EPA. J'" / <br /> Name: A in" Tine: C- o vt'Lv c4�et• Signature: Date <br /> iflltilliflYfiiRlRti#iiflftff#it}iff#!i#iilfti}lifiii#i\}i##iYilRfFifi#t}'#i#tfii#iiii#HAiiftltiiiiitii <br /> SECTION 4.To be signed and dated by an authorized representative Of the treatment,storage..or disposal fadlnp <br /> accepting tank andfcr pipina <br /> FaJfty,Name:,IAXs�— C b.&,r-,,T�' eaVrT <br /> Address: i)-.I I $ . j S-��� a� �'L,d , cit>. yT v�e �• Zip: q�3 b I <br /> Phones:i7.60 - L'(,Q� C 115 <br /> Date Tan Received: r '`s'4', TL �..Ol <br /> NameTela: 2. Signature. <br /> i <br /> EH 23 046 (Revived 07.2? 10) 9 <br />