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0 <br />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 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 NAME: 5,4A .Mau?/,a STi? /G / <br />FACILITY ADDRESS: .-5 i " g/ G/.ifl)S/ffy[ T- <br />7 r� d 4F <br />TANK ID #39 -�'� TANK SIZE: // /N PREVIOUS TANK CONTENTS:. i? <br />SECTION 2 - To be filled out by funk removal contractor: <br />�J <br />Tank Removal Contractor: % y /NU/-et2,t: ®/L /,,je, <br />Address: Po l3U X 3 5 7 City: &' ew / Zip: C%S <br />Phone#:( 1051) 3/'j; -617S Date Tank Removed: <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. J //%J //)!d/zl�� d// /jC, <br />Address: d Sox 3 ts <br />7 City: Zoo/ <br />Zip: <br />Phone #: Z�' _ 3 61 75 <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 />11 <br />Name:% 07'/N //y0/�I)/Z Title:( �2 �1 //(�C_7 /Z Signature: Date <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />01 accepting tank and/or piping. <br />/A,JKS r� q <br />Facility Name: Ct/E 5 % Cdi -S %�Ct_r//.�,/!9£,t/% <br />Address: /,�7,6Z I Sa,,i/t! ,./uNEi2 City: %v,?ZOC/f Zip: Gj5 3,f�/ <br />Phone#: <br />Date Tank Received: <br />S71�-rL 1'j �/nl.s moo: SAN V1rot5 STS ,�EL P{2a0✓c7"S. <br />AtlJatss / Z-000 /'OL Sc)/y! /�e174v iZAn7CNU COZ064,14 <br />3 <br />f4ajex ('716- <br />/10,2111 5 <br />"7/6/gp)11ess S, 461S7"1,J {2,944 ✓.17i1•-J%EL9 C9• q�}j� <br />1'//0.^16 4 (Zv f) c ffJ . 4b) 0 Jr (�/.G,JAid,2e <br />EH 23 046 (Revised 10/30/12) <br />