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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 />».....................»».»»,»,..,.»,.,,.......*.,.,.........»...»....,.. ».,.,.,... <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 Envient <br />acceptance of the tank by the disposal or recycling facility. ronmental Health Departmwithin 30 days of <br />and returned. The permit holder is responsible for ensuring that this form is completed <br />FACILITY <br />FACILITY <br />TANK ID #39 - NK <br />SECTION 2 - To be filled out by tank removal contractor: <br />TANK CONTENTS: -d % <br />r <br />Tank Removal Contractor; J% eV 1611)/? i7t 0& /,VC, <br />Address: 20 i3e))( 34; % City; Z— ew i <br />Zip: <br />Phone #: ( Z (1 i )_ 3G4-61,75 Date Tank Removed. <br />++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor_=Z /5 % /Jjzi,7, gJ/ /,,dC <br />Address: P o Jox 4';7 City: Zoo/ Zip: 9 S 2 - <br />Phone #: ( Zeri i <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 />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />V %Anl K S TUaccepting tank and/or piping. <br />Facility <br />0 <br />cy�y �y _ <br />Address:_ S 74 / wFj--4 City: /L'Iui Zip:c, S'3� <br />Phone#:(209)_g � CL9k' <br />Date Tank <br />Name: Title: Signature: Date <br />TrEL !i/�in7� >D <br />Avl)at Ss <br />3 <br />SThrA)lTZAt/Z S72�-tZ- PROv✓cTS <br />/Z-,1100- / OGSv/�j r2e� 9v i�v9n9CNrJ C�llr7crJ y j ��fL <br />To: /�OyIIGt+rsf2p /-/C,, <br />/40%/lfSt / / r/ S, /lj 0S 7-1,j %2a9.4,3 <br />-# (Zo9 <br />EH 23 046 (Revised <br />✓/J�9JTFC9 C•9• q3�� <br />