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WWI <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQM COUNTY <br /> Telephone: (209)468-3420 Fax:(209)468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ».......».... ,.».»»......».»»... »....»,»......»».............»..... <br /> SECTION t - 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 NAME J LLL° <br /> FACILITY ADDRESS: 02�F n l! E• �U j 8 — <br /> TANK ID#39- 0/Rj En qL TANK SIZE 1Zi J00 PREVIOUS TANK CONTENTS: cD� <br /> xrrr+xrrrxrww+rrrrrrr+wrrrrr+xrrrrrrrwwwrrarrwwwwwarrrwwfrr++erfwrrfrrrr+wefwwf+fr*rrrwf+++++++++f+++rrr <br /> SECTION 2-To be filled out by tank removal contractor. <br /> Tank Removal Contractor. .1r� f�p <br /> Address: LKLL,n !1'1_7 )t "I l 'F ptQ City: ZIp: s <br /> Phone R:l:�05 R 3.1 D (g Date Tank Removed: <br /> ++rrrrr+xxrrrrrwxxrrrrxx+rrr++rxxrrrrt+rrrrrrwxxxxrrrrrewxf.rrrrwr+wr++frfrrwrtrtxrr+rrwftrrermfffv+rx+ <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: -j 2 <br /> Address:,q 11p ±)i,--y99 7 ' '� C Tip: q <br /> Phone#. QD QJ1 ) 9-:, —n(,y <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner aArequired by Cal EPA. <br /> Name:k n Tide: jPJ Signature: Dat " I <br /> rxwrxwxwrrwwrxrarrrrwrxrrrxrxrrrrr++wwxwxrrrwrwx+xrrrwwww+rrrwrr+xrxrrrrrxrxxwxrxrrrr+rxxxrrrrrwxwwxrxrr <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> acceptingtank and/or piping. D <br /> Facility Name: LR-11'%J-v ('S!i ) 1�0 Y[11, r 2 <br /> 1 V p �_ �� <br /> Address:_�-,--7)0 QQ C �/d m i n City' 6 ✓/ Zip: La.- <br /> Phone#f4.0 I ) <br /> Data Tank Received: <br /> Name: Title:LSignature:LL A, Date <br /> EH 23 046 (Revised 10/30/12) 9 <br />