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iIDECEIVED <br />ENVIRONMENTAL HEALTH DEPARTMM6 8015 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL <br />' riC�'TrJ nCO�?T!t!tCNT <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 — 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 <br />FACILITY <br />TANK ID #39 - TANK SIZE: 5�5 27:�' PREVIOUS TANK CONTENTS: /ASVD ®iL <br />zzzz�i>FiFzzzzzzzzzz�«zzzzzz�zzzzzzzxzzzz�zzz�z,tzzzxz�zzzzzz�zzz�zzzzzzzz*zz�+zzzzzzzzzzzzzzzzzzzzzzzzzzzz� <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: �i�(J✓�I�� B/L /--Jc . <br />Address: D /3a�X 3.5 % City:_ cf�®o j Zip: 6 � T <br />Phone #: (20 / ) 3292 3 ? % Date Tank Removed. <br />zzzzzzzzzzz+rzzz+zzzz«z,tzzzzzzzzzzzzzzzzz:rzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzxzzzzzzzzzxzzzzzzzzzzzzzzzz <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: ©/` /d✓c <br />Address:�8� 517 / City: Zip: <br />Phone #: ( 2- 16 —3 2 97 !;XP - <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: /i�%�'iC//�1/7 I2P _9�_ Title: �,d7 7 1Z signature:. Date <br />rzzzxzzzzzzzzxzzzzzzzzzzzzzzzzzzzzzzzz�zzz*z+zzzzzzzzzz+zzzzzz+zzzzzzzzzzzzzzzzzzzzzzzzzzzz,tz,ezzzztzzzzz <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: jr, ),fz//) x oc. <br />Address: 7 9� S- �Y./"IS q'r�/ n��Q City: a±,i)EecG% Zip: <7' <br />Phone #: <br />Date Tank Received: <br />I/�� i 71%/C /1 4 Dodli4F_ 1�-Ia£,( {ri G?SS PJf✓�n/S- Col(.�/i�! ,5'S0 E9�Lt�i7 <br />4")p C"sJ Bs- Gff e, b) 1 oA G✓lCL 8E <br />i�ias�J�ic£J/ (�NuL£// 10 cv��.a2J /�iIG. g7lf% fJilpaS'f�'oi�QS/ STT. U_ <br />EH 23 046 (Revised 10/30/12) <br />