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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 /> 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 NAME: I L <br /> FACILITY ADDRESS: oC £• Q JLA j2� <br /> TANK ID#39-&9Iff03 TANK SIZE: /4 OOO PREVIOUS TANK CONTENTS: <br /> ...•..:.x�k++++.+�«..•..err++�+.•www+�wxww,e:rw��r���,r�+�+�w�:w+.:•x•ex•«eww,ewwwwwr.��.::�wrr��:�:�+.,rw:r���� <br /> SECTION 2-To be filled out by tank removal contractor. <br /> Tank Removal Contractor. n <br /> Address: �/�1='� ,� Cl 9 E145 /4'� City: CQinc 194alzip: 01 <br /> Phone#: ( _)���—''�t'n t7 Date Tank Removed: <br /> w,e��:�:,r:�:�•w.x�r������x:+•xxxwx���r��r�:������•�,rx•xw�w«w����rx:�xw��x��+:�:t���.�•.�+++�+++x..«<..+�+ <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <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 /> 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: Zip: <br /> Phone#:�) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/30/12) 9 <br />