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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. t <br />FACILITY NAME:—.54A T(L4 �1//.y /Zc�/0AJ!,9L // _45-1 T /)/ S/i?/C 7 - <br />FACILITY <br />FACILITY ADDRESS ' E <br />N / <br />TANK ID #39 - t Q TANK SIZE: /�� PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by thank removal contractor: <br />Tank Removal Contractor: �J i/Ii �N.J/� I2,_ Ole 1,46 <br />Address: _ Po i3e) X,' 7 City: Z-01311 Zip: C/! / <br />Phone #: ( 2 C C,) Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. _i _ 71j/d/Zr2g d/e /ndC <br />s' <br />Address: [3©X 35Z City: Gy/ Zip: C/ 5 L �fl <br />Phone#: e'6!1,7S <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:M,T,G/-J Title:L _r%.J7✓i e--1 %Z Signature: Date <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />01 %A.JK S 70 <br />accepting tank and/or piping. <br />Facility Name: Cf�E s % Ct%fS %� (ri//r�.i%if1✓/ <br />Address:�lT oZ /5 ✓7 � uNER City: /v.r?1-0C/f Zip: c% 5 j,y% <br />Phone #: ( 2 0 I )�//IL 93 78' <br />Date Tank Received: <br />Name: Title: Signature: Date <br />�T=tL�'��'i,�� >'o� SINN/Tz�/Z 5��=�L r��'u�✓c 7'S <br />ADf)/2FSS / LVUr)' /`aL-Sc)/j? r2v%4il iZ/9rJCNt7 C�,zJc�✓� q� �y-L <br />ri�tQ6�4SS Tp <br />/ ///,✓s Rovnfss 9I9 y s. /�t�s T. J ;2��v .��9 JTFc-9 c9• �3�s�G <br />elidefi 4 (ZUCI) C/<2-7 <br />EH 23 046 <br />