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11 <br />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 7 — 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. c 1 q <br />FACILITY NAME:_, 1YA:,&al//rJ Z:_41 A).9L T dl SZ—F/G > <br />FACILITY ADDRESS: 1_513 3 E%. Z <br />TANK ID #39 - ¢ O i I S�' 1 TANK SIZE: ,WEOOO PREVIOUS TANK CONTENTS: <br />--------------- <br />SECTION 2 - To be filled out b•• --y tank removal contractor: <br />Tank Removal Contractor_ J//%J rpt ®/( /,•r/G <br />Address: PO 1 X City: Zip: !2i.? <br />Phone #: ( Z. 0 i 1 3167� 6 / J S Date Tank Removed: <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: Z7_, ' 7k fZ,9, <br />Address: d joX 3 t5 <br />7 City: Zip: G/ S L V-� <br />Phone #:( 36e6;125 <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 />,f 1 <br />Name:1Z4XT//'V //y0/�l�/� Title:( �2-1 //j�(' %p /Z Signature: Date <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />01 —�niKS accepting tank and/or piping. <br />/�% <br />Facility Name: CV65 % <br />Address: Sail—72./;/UEiZ city: TvRGack zip: 9l 3el <br />Phone #: ( 2, V /) /:7 �j is , %3 %.X <br />Date Tank Received: <br />ST�tL ri/�in1,f >o� S�f/NrTzc/Z S�s-�L r'�2of)✓c TS <br />Avl)/Ztss zuv0- &S01,1 r2r)4L) 1R,146NC) C0,10Oa,4 9s7 z <br />3 <br />_ P110„lest (C?16 yds - ty <br />i ic3t A'6tFSS Tp /�0Ra4lZp /We-, <br />f///✓S <br />111va/s5 9792 S. /JfNSTit) i2��eRr) ✓yli9J%EC9 C-9• �Ji�3G <br />l'7/16.4t 4 (z'y>) c/ L • �J S/S/19Ai✓?r <br />EH 23 046 (Revised 10/30/12) 9 <br />