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! 0 <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 /> *####www#*w*#*#rt*####www****##wwwwrt#*w###ww###**#w#wwww#w**rt######w###a ►#****####ww#w*##*#r##w##*##rt#####w� <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 /> FAC II.,ITYNAME: i.0&T- CA4_1 T-0 42MI A-- SAS �.- J . 0 t72 <br /> FACILITY ADDRESS: W47 Y—Ow—I:R C AV9, , 51-0�(G j�3^} f C.� 6M,S;2-4-7 <br /> TANK ID#39- 6 SO l TANK, SIZE; 12-1000 PREVIOUS TANK CONTENTS: So�j t <br /> t#*rt###+#w*###rt#4#*##*#######*######w##rt#rt##w######w#rt##i#+i####w#######w*####+k#####rt####M*###**###w#####*#• <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractors�(,� �G �S S o d(�-4'S `V l C. <br /> Address: -11 aed &M City: A <br /> Phone#:( Cfi ) 1- Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: eZ 0y1 1 '�p <br /> a P ct�+ of -�- ,yv�pt�ri ,rc� r.�ost�r e pro c ii-co r� <br /> Address: <br /> City; Lip: <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 /> #######rt##########w*+#*##########rtrt####rt#rt###*rt#w####rt#rt######w#w####rt##rt#www########w#######*#wRrt####rt##rt• <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: ,Lip; <br /> Phone#: (- - <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ##*##*##w#w##wwww#*rtrtrt#ww*##rt**rt###ww#****rt####w########*www#rtrt##*####w######rt###*###*######*###*rt##**### <br /> EH 23 046 (Revised 11121/06) 10 <br />