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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 - SIC 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 <br /> completed and retumed. eG�j�LL/.tl ,P'9L SSTT� /�JdESy�/f.✓7"I <br /> FACILITY NAME: QdW E IZ INI,-J G E ///11 Ant% LO T <br /> FACILrrY ADDRESS: 0Z 51t S. G L 109994//Q <br /> TANK ID#39-OE 11801`1 TANK SIZE: 4200 PREVIOUS TANK CONTENTS: dn7� <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Ole- 14e- <br /> Address: P0 B D X i 3GS 7 City: "ID / Zip: c1S'A 94 / <br /> Phone#:( ,_ 3 2- Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: .J/^7/Y) D/L <br /> Address: 90 60)C / <br /> `3 City: Z67V ZIP:_ 5OZ 'f <br /> Phone#:(,2091 Z9S (f <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,"ol 715-471WP ?S- Title:6WZbfC�� Signature: Date <br /> q**#*iii+rt+M##**iW1444**rt*i+rti*i####WW#*44##rt#***Fi*Wii**###*#irti**WWWW4#k**#i*iiiiiiiWWW#i#WWWWWW*t#WliW <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: Sc_-11oJ/ TZ4X 57�el &Wc/L7S <br /> 19�cN0 <br /> Address: /ol. OOD 5o091 3,16,12 City: Cott dW4 Zip: �'57�7 Z <br /> Phone#:( 0114) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 12/31/07) 10 <br />