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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 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. C "q "� <br />FACILITY NAME: SAa:dIAT dt/1r1 22- jQeyaz 7/ -IS-j % d / SrzflC 7 - <br />FACILITY <br />FACILITY ADDRESS: /-5-33 <br />TANK ID #39 - TANK SIZE: REVIOUS TANK CONTENTS: 01,F QeZ <br />SECTION 2 - To be filled out by tank removal contractor <br />Tank Removal Contractor. 7ji n V/Z t2z: o/L /"je, <br />Address: I'D U X S / City: 'e-1 Zip: C% <br />Phone #: (ZC'I)_ 367j' 6 175 Date Tank Removed: <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: :57/97 <br />Address: <br />ie 0 3©X 3 57 City: Zip: 9 } 2 - <br />Phone #: Z±) _ 3 6 9- 6/ 7 S <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:1X,4Q71-N 7/y0/2y)Lj;— 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 />/A+.liKS To accepting q <br />Facility Name: W6 S 7 C0 4S- <br />Address: a �,./�N�/2 City: %yi -e0Ctk zip: ''l5 3�% <br />Phone #: 0 <br />Date Tank Received: <br />Name: Title: Signature: Date <br />ST:rL l'�r'i,vt >o SGN�11/Tzc"/Z Sit ,6EL ikoL)✓C r5 <br />4001ZtS5 ! L �o0- iZ9a6NrJ C�^zJcJi4 �7j 7�/L <br />3 f/1ajezt (g16)98s-4t '-T1a s/�,✓�/-� <br />iit A'S�9SS Tp <br />7 J <br />{ ///.✓d A0'),11 5 ?999 S. 40- Tri J /2v -4r) ✓YJij�l%E�9 c9- �J�}3G <br />f71104b 4 (Z -VC/) �/ L • �f) �trr 5/Sn9Aid?t ' <br />EH 23 046 (Revised 10/30/12) 9 <br />