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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 returned. <br /> FACILITYNAAIE: <br /> FACILITY ADDRESS: �6 /✓' cG / <br /> TANK ID#39- TANK SIZE: /OO PREVIOUS TANK CONTENTS: CeV eVC7 �i <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor. �.—zn /1740y2PE Ole /aC <br /> Address: ?a 7c9X . 3 5-7 City: Comd Zip: / 5�9"1 <br /> Phone#:( � >pjo ,e'� �S Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: j 7:71 �P Ole /,:�OC' <br /> Address: �Q `�Q City: O{' Zip: <br /> Phone#:c26—.16 7 5- <br /> Authorized <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. pp <br /> Name:X /?Zj /Ate £Title: e 0�/��7C-<Signature:-/-- Date <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&,W/ 7Ze/2 ST�F� <br /> 1tE.4/e!S/O <br /> Address: <br /> /A 1!26,0 f-DZ'Sr7lrl 1-3) city: e,1RCD12(14 zip: <br /> Phone#:C2& 7Jr-S- <br /> Date Tank Received: <br /> Name: Title: %pature: Date <br /> EH 23 046 (Revised 12/31/07) 10 <br />