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0 <br />0 wcelweb <br />SAN JOAQUIN COUNTY S E P 0 1 2004 <br />N <br />ENVIROMENTAL HEAL'T'H DEPARTMENT <br />LII DERGROUND STORAGE TANK DISPOSITION TRACKING RECORDENVIRONMENT HEALN <br />PERMIT/SERVICES <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 />FACLL.TIY NAIiIE:_v <br />FACILITYADDRESS: <br />_�.r� �/ /%%/%l/�/ S/ ,�lf}Gf�/•.� �` �/ <br />TANK M #39 - TANK SIZE: PREVIOUS TANK CONTI TS:° <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address;Z,Z !' City / Zip: Ic Z f e <br />Phone r: (6 Date Tank Removed: <br />K##rtrt###1MwKK+Ie.##k#kFk*"Mak*rt#k*##M#KKiRs##*k#*#"k###ww+k#11�w�11 ;w#+IFF#�N##Frt#*#M K�t1kF###wllf#M*#Ki"#�M#iK#K+k F##�kKKrt##Fs###�K <br />SECTION 3 - To be filled out by contractor " decontaminating tank": <br />Tank Decontamination Contractor: /c,�/ �'? 1�/ Y��'f 19 //1 <br />Address: 7� t C—�Tj r City: G©��t� Zip: +� <br />Phone #: ( 2 -Or �)_ �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:1 '� 0�;f_ Signature: Datc <br />•rtrt#rtrt#rtrt#rt####wK###rt###rt�K##rt####KK## ####="Kip#Kskizsk#�:#S C# M"K����##��`�#'�•�##rtK#'K**###wwY##*krt#1/yiK 1M#k#K#* *#### <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: Q �,'7 CU. City: <br />Phone#:1 <br />Date Tank Received: -( 7 - <br />Name:- <br />Name;= L eA,,'c� a, Signature: <br />rtrtrt#rtrts#rtrtrtrtrt#*ar�rtrtrtrtrtrt�M#K*##rtrt#�.�pK#rtrt*#**�#rtrtrt�****rt#ee*sK*##****� <br />EH 23 046 (Revised 3115/02) Page 10 <br />Zip S <br />i <br />ti <br />