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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> »».............»............».......................................................................... <br /> SECTION 1 - SJC Environmental Health Departmenfs Tank Tracking Sheet shall accompany each tank affixed vulh 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: � <br /> FACILITY ADDRESS: 92131 c• �114rGL_ <br /> TANK ID#39-QfS I£fO,J TANK SIZE: I2r 2DO PREVIOUS TANK CONTENTS: <br /> leiwwfriirwwwriwwrwwiiwwrrer}w!#rwwfrrrwf+wrrrwwferwwewrieiwww###w#wwaarfwwraarwiw#rrarirwwrwriiwwwrrrww <br /> SECTION 2-To be filled out by tank removal contractor. <br /> Tank Removal Contractor- <br /> Addmss: L}q-/ Ilt <br /> Phone#:�)!] 3, = La Data Tank Removed: <br /> r#rwwwawx#wwmwwwarrwwr#ywwawraiwwwwaae#arrwwwwaaa#wrarrrwwrwrrw#wwr#rrewwww#:rw#rrwarawwrrrwrwwwwmrww# <br /> SECTION 3-To be filled out by contractor"decontaminating tank-: <br /> Tank De ontt9mination Co'nttractor. /] p C <br /> Address:'"ttw Fl7ll��/ —1 -1 �-�C C Zip:9��-� _5 <br /> Phone*(� •� ) -L S - (D <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner quired by Cal EPA. n <br /> Name: TNe:'F'1)r, Signature: Date <br /> !yw#wwwrwfwf#wwRrrrawf!!}if#frw#iwwR}!!#iw##}#w! ##}w!r###fwlR##i##ff}wwaliR#wwR#ri##}#waRwr##rr##aw##wa <br /> SECTION 4-To be signed and dated by an authorized mpresentatNe of the treatment,storage,or disposal facility <br /> accepting tank arid/or piping- <br /> Facility Name: �^ l/ � <br /> Address: S', City. Zip: I?S�O .D <br /> Data Tank Received: <br /> Nam : Title: gnature: ate ��f� <br /> EH 23 046 (Revised 10/30/12) 9 <br />