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• • <br /> 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 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 <br /> completed and returned. <br /> FACILITY NAME: CA-LI-r-0901 A- QPAS *,a 172. <br /> FACILITY ADDRESS: 72 -7 11"AcIPt C-AVG ) S'T'O con.—I- 10 � G'A, 06Z0`7- <br /> TANK ID#39- TASIZE: <br /> �_PREVIOUS TANK CONTENTS: rv� <br /> #w##########rtwW############rtW######4##WWW#W######rtrt##Wrt###rt#w###rt####+rt####+##########*w##############w#*## <br /> SECTION 2-To be filled out by tank removal contractor: �-4 <br /> Tank Removal Contractor: _o 5pU ek ° A sS'�00jFP j Inc . - <br /> Address: ' BC/1 r vi 1.oU —city: t 1� �S Zip: <br /> Phone#: ( C4 Q01 (jQLR-(I 36'Lq_ Date Tank Removed:_ �BD <br /> wrt#Ww###########w##w#######*#rt#wWWWrtw######WWW###w#+#w###Wrt###+########W##########rtWW###+*#####w#######*##w <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: YCy � T 0 <br /> Address: tGN1{aorGyq c I osu rc pra cid__rf . <br /> City: Zip: <br /> Phone#: ( j <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 /> ####+####wrt#####wrt+rtwW+###w#######WW**###w####*#W####rt######WwW####s###+#w#########+*+#*#######+#w##w####*# <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: <br /> City: Zip: <br /> Phone{#: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> #+##w**#w###rt**###wrt**#w+#***#*##w##w+Ww#rt#*#rtrtwrtwW##*###rtW###w###w#sw###*s*#*+##*w*##ww++*#*#w*+#+###*#w <br /> EH 23 046 (Revised 11/21/06) 10 <br />