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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK IMSPOSITION TRACENC RECORD <br /> tt\trPNbrf\N ti ss sHNtNaiyMtgtstgystssasftsssalgsglttgysqatyssf yspltggl q s!llrtsss asltH <br /> §ECTION 1-SJC Euviromnental Health Department's Teak Tracking Sheet shall aceompmty each tense affixed with its site <br /> identification number. The Tank Traclmy;Sbw is to be rotm ed to the Euvaonmennl Health Department wlthdn 30 days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responttble for c mmn that this form is completed <br /> and resumed <br /> FACHMNAME: <br /> FACILITYADDRESS: D'e/ice �/yF° OF of 1 DDICA iD d A),eQFor <br /> TANK ID 939- 0 09 TANK SUE, / Sa CI PMMOUS TANK CONTENTS: <br /> sgsTlttrtgyfafasws.\lltft*rryrttll/atiTlpattbsssssgyts#glslLHWpsttlHisNssNisssissssaggal;s <br /> SECTION 2-To be tilled out by tank removal contractor: <br /> rank Removal Cvratecm� G e-o �o.� T.�� . <br /> Address: (o p.,.,t.� (-. S�e l� city.. Ste.«-�.-..z-�o zp: 9 S X 3 l <br /> rrriarT T tytytrtlssq taataygaa aq\assssua gatstlssyatrtrtawr....t.tga!►t\tyasas.ltrtttysssslplaaf <br /> SECTION 3-To be ffW out by contractor"docontamiaating tank"; <br /> 1~aok Deconanonatioa Cormaetor: <br /> Address: r City�/fh iP: 9y��t <br /> Phone#-. <br /> Aathodad repromestive of couhacm cefnfylag tlaotgh aigoatme below that the talc has been demntmmnated in an approved <br /> roamer as required by Gal EPA. // <br /> Namm-2a= p C �Ji�r6lTitle: 72-wtA f SrnrSigmtum. Date <br /> isgtgltesttet\►tsgsssatrtrartsssgyfrsaayfTTrtys\\a\asF►atsistrt ttstssaalrtggglyyMMtlttss+►t/st! <br /> SEC71ON 4-To be signed and dated by as authorized represeatativa of the trealme t,storage,or disposal tkeility <br /> acCcp°°g tank <br /> a& _ / Ta+f- 3/09oZ <br /> FacilityNaor rr�D0 < O04 /Ol i1Ar/S„2/in 5 t <br /> Address: a �- /Ll ,C3/r�a� '['rL Zip: <br /> Pbow <br /> Date Tank Received: oZ <br /> Na-=,V*.f <br /> s\sss.s\wan atT\\Mttar•rasaaMarssyrtitttt�apltMlNNttsas»►sNt\►ssiT.yltyMltrltrtlpttsNgttatatt <br /> EH 23 046 (Rcviscd l0(l6/03) Pap 30 <br />