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04/19/2005 10:03 2093694220 NEIL ANDERSON ENVIRO PAGE 03103 <br /> 0 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL FIEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> *w*��*��*ro*rod+*m+ttwwrow w+*,�w****ro***w****wr+wwww**+k*M*ae*a*pwwwwwwF*�Mw+**+ks***w�awwrr+rwww�N p,k**ro**:nt*rwrp+wwww <br /> SECTION 1–SJC Environmental Health Department',Tank Tmcking Sheet shall accompany each tank airmcd with its site <br /> identification number. The Tank Tracking Sheet is to be returned to the Environmental Hcalth Department within in 30 days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this fonn is completed <br /> and returned. <br /> FACJLITY NAME-. /I 1 C� � V RfrC 1 <br /> FACILITY ADDRTr,SSb 3 �cE LAN V '7 ftT 'CIT'WMIN 2-10 <br /> TANK IJ)439-18:! 1 " %% ANK SIZE: L Z 0()" PRFVJOUS TANK CONTENTS <br /> *wMk+kw*++�******wwt+w+k*Afi+w*x***m*twwMww*+gas*a.+t�:wrty�wd�y�*+w*Mw*wwwwM+M�****rox*wwswwwM�*******s*wpwMwrt�*s*ro****w <br /> SECTION 2-To be filled out by tank removal contractor; <br /> Tank Removal Contractor,- _M01 N r <br /> Address_ �� 44 00 city:_W zip; L(5 <br /> Phone#;l _ D -Q (bate To.nk Removed: <br /> ****wwwwwww****•**wwwww+*******+*wwww++*w******www�h++k*roa***#we�MM***,�■wM+ www,�***,�w,�wrr+YM�NrsF�kAs,kww�ewwww**w*#w*�o <br /> SECTION 3-To be filled out by Contractor"decontaminating tants" <br /> Tank Decontamination Contractor, <br /> p <br /> Address: City- N %ip:_ 1 If 560 <br /> Phoned <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal FPA. <br /> Name: _Title: Signature: Date <br /> SECTION 4-To o 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: �� �� lllli �� City. _ Zip:q<218 —, <br /> Phone : )_ '�b X37 0 <br /> Dote Tank Rcecived: <br /> Name; Title; Signature:i_. <br /> ******#ww*+*eww+�yw*ro**ww+wok**w*mwww+�s***+xww***ro*w*w+i+i*ro***+y.*�e*ro*wwwwak�;rsw**+kwaw*w9+#w*k++roi+M*�#**wwt+kM <br /> EH 23 040 (Revised If)/]6/43) Page 10 <br />