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0 0 <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 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. <br />FACILITY NAME: 5N J�14011/.) T /]/ / <br />SECTION 2 - To be filled out by tank removal contractor <br />TANK CONTENTS: d Tic o,QiL <br />Tank Removal Contractor: ✓% y //1O/ I2t ®/Z /,'JG. <br />Address: PO UX 3t~7 City: /—[7 Zip: CJS •,L. !�K <br />Phone #: ( Z C i) 3j' *617, Date Tank Removed <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. .di //i'1 •//fid/Zt�� d/� 1�je-, <br />Address: e Sox 3 t .7 City: Z—a01 Zip: 9 L 7`-/ <br />Phone #: Ze 3 6 *y 6 / /7!5 <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:1XdW//-'JTitle:(�9..J//l e -70/Z Signature: Date <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <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 />_ q <br />Facility Name: 06'5 % C(iiYS �� (,{�///✓,!/J��% <br />Address: -54%ga -7276/UE{Z City: Zip: 9 <br />Phone#:( Z0)Ko!�9—. C�3 7.1 <br />Date Tank <br />Name: Title: Signature: Date <br />PR&I)✓c TS <br />AOJatss / L000- rOGScJ/// fzemo fZ9n9CRC/ Coiz,)oV/¢ 9:i 7'/-L <br />riot QtSl.4SS To /'01?a4np /we--, <br />{ ///i✓S 40,21113 s 99 S 9 S, 4NS %i --j R,%,70 ✓/9/9 JTFC9 C•�• L3�}�G <br />f'No.4E -d (z09) clg-z yg- S/S4,i7,17f ' <br />EH 23 046 (Revised 10/30/12) q <br />