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0 <br />E <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 3o 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 - S '2ANK SIZE: OO ZL900PREVIOLIS TANK CONTENTS: U.t fct�JE'D GifS'0 �/.✓� <br />/ —�— - - <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor. <br />Address: 2Q 3n X ' % City: L eJ/) / <br />ZiP:C/7,�-5% / <br />Phone #: ( Z. 0'7) 367* 6 / Z,5 Date Tank Removed: <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. <br />City: Z 0/0 / Zip:. 2 S L �,/ <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:/% W7� //YOWi <br />SECTION 4 - To be signed and dated by an authorized representative of the <br />treatmentl, storage, or or disposal �f�ac�il5ity <br />V accepting tank and/or piping. <br />Facility Name:Igt� /LLW�iDlic�y <br />Address:_Zip: <br />Phone#:(2, vJ) �l3� .412— <br />Date <br />TZDate <br />Tank <br />S T�tL !i/�in1d �o <br />rr;;'' A vf)izt s s <br />i-ic3t �6C:4SS <br />Title: Signature: Date <br />S c -,IV IV1 Ta c i2 S T t L P/C O I)J C 7—S <br />ZvU0' rOGS�/y! R0 <br />40 /Zgn9CNC/ 6WZJcrk/,¢ 9j 7.f4Z <br />Tj) I'07la4111,3� /w e-, <br />EH 23 046 (Revised 10/30/12) <br />