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s • <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 />..............................................................»,,...,,..,.,,,,...,..,.,,.,,.,,.,,,.....,,, <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 <br />FACILITY <br />TANK ID #39-961 <br />39 - 9 bl I S 91 TANK SIZE: ety U PREVIOUS TANK <br />a , I n. , <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor. ✓ j /)'J 721,, /? i2t ®/,! /,46, <br />Address: hO 3t_))( 3 t; 7 City: L e) I Zip: <br />Phone #:( Z0 �7) Date Tank Removed: <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination <br />Address: it 0 L:5© /X 5 7 City: z e/-) / <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:/%%X71_-J Title:( r24 & _/02 Signature: Date <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />Toaccepting tank and/or piping. q <br />Facility Name: 065 s 7 C04.i 7, OL& P.�n�,✓ i <br />Address: /sT+vZ / SZT1Y —7 o;NOR City:-- y,QZ0C/K Zip: 91! 3S- <br />Phone#: Zt 93 29 <br />Date Tank Received: <br />Name: Title: Signature: Date <br />� 1r,7,t /Z S7,, L r✓c TS <br />ADl)4tSS ! L d00 rOGSe/v7 (20_)>4L) RAA)CAV Co, -z v.r¢ 9�,r 7'Lz <br />(1716) G <br />ric3;=^'SLFSS Tp �OIlt;dsfRp /�✓�, <br />9999 S, ✓0S7,, -J Ra.40 <br />EH 23 046 (Revised 10/30/12) 9 <br />