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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (249) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ######**rt##################rt###########*##rtMrt#*#rtrt#######M#*WM#######**##rt##########*#WWMW##**#M#**#*####*# <br /> SECTION 1 - S3C 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: %5S1- C- t i- o9sji A- QAS s �"��-. ;O&172 <br /> FACILITY ADDRESS: -X,+7 -1?-Ac t�R c Avg , 5ro CAnJZ*34 0A OFF-0"7 <br /> TANK ID#39- TANK SIZE: 12.fid 0 D PREVIOUS TANK CONTENTS: - <br /> SECTION 2-To be filled out by tank removal contractor: n ' <br /> Tank Removal Contractor: l P Cso Vr <br /> Address: 6411 1aaA City: N,rko Ila Zip:_q_r]a <br /> Phone#: (`��}�1 ) Date Tank Removed; <br /> SECTION 3-To be filled out by contractor"dec"o"ntaminating tank": <br /> Tank Decontamination Contractor: I ut4 n I hCl;h 4N LWJ PusonvAcl 0+1 2 1� <br /> o <br /> TLA -t"cmjoo y prouzw r G <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 /> +##M###rt*#######rt##**#**#+*M##*####*###*#***#rt#***#**#*M#*WWM####M#W#W####t###*#*#******#*#rt**#****##***#s# <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 /> EH 23 046 (Revised 11/21/06) 10 <br />