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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ##wrt*w#w#**#rt###wrt*###rt###wr*###«###w**##rt#####r#*#rr**##*#**#rt*#*#r##*#r*#####*########w#*######*#w#*###rr <br /> SECTION 1—SJC 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 completed <br /> and returned. <br /> FACILITY NAME:_ ske\ 9,j A e c,r <br /> FACILITY ADDRESS: 2s ><S £, ELw y ( F0.r.V.n al 4 3 G d 95- D-30 <br /> TANK ID#39- TANK SIZE: P-3-0 SO PREVIOUS TANK CONTENTS: O nic- w e l <br /> ######w#***###rt**#**##ww***##*##w*«*###wwww*#**###w#rtrt***####rt#*#*#####**#######rt#rr*rt#w##wr*#**##*##rr#### <br /> SECTION 2-To be filled out by^itank removal contractor: <br /> Tank Removal Contractor: Al(Uan --e CG e0 CA V I r,0^AMen�a. � <br /> Address: 937 S L&v ai City: ,C4v,Kl-&- Zip: `-S"A I S <br /> Phone#: Z( •al ) Lib7 1000, Date Tank Removed: <br /> w##*wwwwww#r«w*«#***###*w#w#ww#wwww***********#*#####wwwrtr«r***######*#*######*#**#*#####*#****#*####rt***rr <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone#: (� <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: Title: Signature: Date <br /> «rr###########*####*###########w##########w#w######wwwwr#wwwwwrtww##*#*#*#*#*##*#*##################*####### <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: <br /> Address: City: Zip: <br /> Phone#:�) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ###############***#4##*######*########r##############«#rrr####www######################################## <br /> EH 23 046 (Revised 10/16/03) Page 10 <br />