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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 /> *#W#4###F#k###W#k###k##rrr#rrrrr\i►ir\riirrrrtffirtrt\\i4#i##1R++###rt##r####i#►#r###Wii#iiitr4i»rir#ti#r»tt##» <br /> SECTION 1 - SIC Environmental Health Department's Tank Tracking Sheet sball 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 Blzzll J R911r L EST9 T� /^1 dEsy�lf,✓7"I <br /> FACILITY NAME: OA;W IZ /019/Ij G E b Af,4,j% ea 7- <br /> FACILITY <br /> FACILITY ADDRESS: O Z1 5`f <br /> TANK ID#39- 19 R G-7 TANK SIZE: 4!Zi20 0 PREVIOUS TANK CONTENTS: Z.14& <br /> iriti#i#+4+s+#4+#kris#4+i4+#########*#«#rrrrrfirf#rt+4R4rt######ffrrsr«rtrrtrrtrt#i*frirrrf#rtrtrtr##►s«**#*##f#t##r <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: uz—,71� O/G /AG . <br /> Address: PO Box- 1 :3 !5-7 City: Z_&D J Zip:_ C:- 94 � <br /> Phone#: Date Tank Removed: <br /> R«#«#ii#iiiiasi###s«#rrr+iti###Wi#*rri#rsr*»####W##war+irrt##*#i+iiirs»r#»r+i+iptrt+++++iir«tr*ir#W##++++++ <br /> SECTION 3-To be filled out by contractor <br /> "decontaminating tank": <br /> Tank Decontamination Contractor: ;07-y 7/:- 1'911- /",C• <br /> Address: & 60)(� 3/ City: LOV J Zip:-27/of <br /> Phone#:(a 0% Z 9 y � <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 /> Name4Ig /d / 0R?5- Title:(-ra GraSignature: Date <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tank <br /> /and/or piping. <br /> Facility Name: <br /> ZPhonAddress: /oL 000 �/1y`D/SD/lp1� L3Ly/0 city: C R JOr/1 Zip: 0/S7 71z- <br /> Phone <br /> e#: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> rkrii4#R#44RRSR#rt#■ir\rtrt#4####«#ir\trfrf►ff#frtrt####W#W#rrffiri#4#4##W#rtr#rfi44+##*#++rt#####i###4######t## <br /> EH 23 046 (Revised 12/31/07) 10 <br />