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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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 completed <br /> and returned. <br /> FACILITY NAME: S -ibtrp N 30- Ca .ep <br /> FACILITY ADDRESS 63 b L-(Nn Vm6 I <br /> 7TbM( C /^ p <br /> 5W <br /> TANK ID 939-TA' O50--N)TANK SIZE: 12-1000- PREVIOUS TANK CONTENTS: AV "-J <br /> SECTION 2-To be filled out byytank removal contractor: �.1 ` 'r <br /> Tank Removal Contractor: ►t'U�'.In 4 9- �I��mr ola1_ w �1-N�l W& <br /> p q / (� <br /> Address: /66 q4 5["A AN6 City: W&AN Zip: `TS6 V <br /> Phone#: -I�Z-� 3 ( `�5 0 0 Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank/": <br /> Tank Decontamination Conttr�raac�ctoopr:A /•`A� Q()' , RkM4t J�`�(� Q�'VC- q <br /> Address: G� 6 1 510 M Lf}N& City: DU VU t Zip: I ��b Ou <br /> Phone#:( 72 5) 307 — 1500 <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 /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tank and/or piping. MM,,�rr <br /> 4ti1�51 � <br /> C�fW T- <br /> yypvµ.ty� <br /> Facility Name: I c 1 y-� <br /> Address: � 1�JWrIUVrll city: - 1"R� Zip: <br /> Phone#:� 6-0 1 GG(;19696 J-370 <br /> Date TankReceived: <br /> J <br /> Name: - Title: Signature: ate ^ <br /> EH 23 046 (Revised 10/16/03) Page 10 <br />