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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> »xx»»rxrxxrxrrrrrr»r+rw»»»wx»»»xrrrr+»xxwxrxxrr+rrrrrwwwr»»»»»wxwrwx»rrr»wrr»rr+wr»rr»»r»»w»»xx»s»»»»rsr+rr <br /> SECTION I-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. . 9 ' / <br /> FACILITY NAME:egC/�d/ylo A16W7 7 L/ Z_C <br /> FACILITY ADDRESS: .2j65 16-;%ewej /J/L. GO/J/ z <br /> TANK ID#39- TANK SIZE: SO© PREVIOUS TANK CONTENTS: U�t/,�itJIrmli <br /> rrrrrrrr»r»»»x»r»xx»rrrrrr»»w»xrx+rwrwrr»»»w»»x»»»»xxrrrrrrw»»rsx»»»x+xrxrrr»rrrr+rwr»»»»swx»»xrwswrrrxrxrx <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: ...,//Y7 ��/ZpL�ele / C_ - <br /> Address: 6 7 FS /• �Q/��f/�D�/' rr / <br /> City: CLQ / Zip: 2::nL 5,4zP <br /> Phone#:( _ 6� !�� 7 S Date Tank Removed: <br /> r»xr»xrrrrtxrxrx»rr+rr+r»»»+»wxw»rwr»r+rwr»w+»rw+wrr»wrw+»xww»»»»»x»rxrtrrtrrrtrtrrtrrtrrtw++w»rwww»»»»sr»»»»rssrr <br /> SECTION 3-To be filled out by contrraactoorr"decontaminating tank": <br /> Tank Decontamination Contractor. �.J /iYj //`fB���- (0/Z <br /> Address: 4`7Z E• 0 City: G!7/0( Zip: SL yCa <br /> Phone#:(�� 6 L7 5 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required bby/Cal <br /> �EPA. ? i <br /> Name:�/�/�//-J //5rO/ZI�� Title: Signature: Date <br /> r+rrarwrrrrrrrrrrr»rw»wr»w»w»+rw»x»»»»xxrxx»rt»xxxx»»w»xawxxxxx»»+x»wxxwxrx»»wr»»wwxx»xr»wwrxrxr»»w»»»rrrrrx <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: <br /> Address: 1iop0 ic �D�SGCY✓( �1city/?Tytfl Zip: <br /> Phone#:(& e/ <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> •rwr+wrxrwrtrrrw»rwr+r»»»++xrx»xrrrxs••rxrrrtxxrrrrrrxrxxr+rxrrrrtw+rr+rrrrrwr»rrwrrrr»rrrxrrrrrsxwxswwrrr»» <br /> EH 23 046 (Revised 10/16/03) Page 10 <br />