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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. ,p <br /> FACILITY NAME:T�� -! L L C <br /> FACILITY ADDRESS: 021 :51 6• <br /> TANK ID#39- d/fi''� ED TANK SIZE: /4 000 PREVIOUS TANK CONTENTS: <br /> .rnt�xw�..f+r�..��.ee+.r.�•ex�axe+���rt+s..f��xevr•��ewfr+r:rer�w..tax«w.ttr�.sr>.t�«r��f+«rt.t�+t..tr��.e����,e��w+t���+ <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor—4-4-- <br /> Address: "- <br /> ! I�B�— It1 )+ 9 -1(� <br /> ona- _A City: Zip: <br /> Phone#: )n D J�e Date Tank Removed: <br /> xx��•z������fr�+zw��:t��x�fx��.�fr�.wfr«�.+rxrxt�:t:t.x��:�.�xx���..,t�:t�<x«�x����+t.e��f�t.�w��.rtx.e+����.�ft��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 />