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SAN.JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I-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: <br /> FACILITY ADDRESS �1 LA N��Y C <br /> TANK ID#39-T :D50.7te ANK SIZE: Z _ PREVIOUS TANK CONTENTS: V <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> City: W Zip: Sty <br /> Address: s� q I <br /> Phone#: 'I(�5 ) `� y C Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: �4�' , , "�-' ' API N}� 7 " �' <br /> Address: Citv-. V�1/�-'� Zip: I q <br /> �5G <br /> Phone#:{ d <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: <br /> 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 <br /> piping. <br /> Facility Name: r 0?,W "✓ <br /> Address: City: Zip: <br /> Phone#:{�t ) 4�� -i, 0 1— <br /> Date Tank Received: <br /> Name: Title: <br /> Signature: Date <br /> EH 23 046 (Revised 10116103) Page 10 <br />