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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQM COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> »x»rtrtrtrrsrt++»+r»»»rwrwrt++rr»rtwr*rrrt++»xxx»»»rwwwrrtr++x»x»»»»rw»rrrsrr+r»sxxxrtrw+rwrrrss+rx»xrx»»rxsrr»rqs <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 returned. ee- <br /> ,8/LL/.J R <br /> ,C4tlQST T� /'l1 d�Sy -✓Tf <br /> FACILITY NAME: WAIF(Z .W/n) L IL n A /1I A.J% LO 7- <br /> FACILITY <br /> FACILITY ADDRESS: O?�/ 572t S. <br /> TANK ID#39-OSl1A q(, TANK SIZE: SOOO PREVIOUS TANK CONTENTS: dn9� <br /> +rrrtrrrsr+rs+»w»rp+xrrwrtsrsxxrt*wwrsxr»xrr»rwrrrrtxrx»rrwwr+rxxrrtwrrwrtr++»»rr+rr++rx»wrtwwrrs»»s»rrtrrtrprs+»x <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Ole- 14c . <br /> Address: 7 0 3 O X ♦-3 !5-7 City: GD/, Zip: <br /> Phone#:(Q 3 L 9'S�O I Date Tank Removed: <br /> *rsrtsxx»»w*rrrs»rx»rrr+»rrt»rtrrtrxrxrrrrrrrr»x»wws+rrrt»r»xxrrs»»xrtrt»rsrw»rtxrrrrtss+»»+rrrsrt+xx»*+rrr*r»rx»**rr <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: .J/I oIV7 �?Vj�/ p/L <br /> Address: �D �O�C / City: Zed / Zip: 2SOt 700y <br /> Phone#:( , 3 2- <br /> 9 �� <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 /> d- T,-?� <br /> Name:/1�ARxTitle:(,F/N7GSignature: Date <br /> rrssw+rtrr»rtrrtss»+x»+ssxrxw+wxxrrrxrwgr++rxrtrrrtr++»x»r*wsr+x»r»»»wrrwrx+x»wrsr+++x*w*r+rs»srtrx+rtr**srrrrrx» <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: S�/'J�I TZ L� S���'/ &0ac,TS <br /> 91ZPh !� 9�JcN0 <br /> Address: /OL DOD(� /:0Z 5&10'1 /3 <br /> 1 L 60 City: CpCottJOt/ij Zip: CY S7 791Z- <br /> Phone#: <br /> one#: <br /> Date Tank Received:- <br /> Name: <br /> eceivedName: Title: Signature: Date <br /> rrxrxrrr»wrrrrs»»rrrsr»rrrrrrrxrrrrr»»»»*r»rr»»»»»rrrrsrtxxxr»w+»r»rtrt»rrrx»rrtxrtwrrrsrrrtrwrrsrr+rrrt»»rrrsrr <br /> EH 23 046 (Revised 12/31/07) 10 <br />