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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 <br />FACILITY <br />TANK ID *39.7Q1L5_f0TANK SIZE: 6000 <br />PREVIOUS TANK CONTENTS: /U G/ O/,' <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor ,-n /A!. <br />Address: 20 X 7 Ge)I / <br />City:— Zip—�S <br />Phone #:( Z. i 13(j r� �p 75 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination <br />Phone #: ( ?–ell) -3 6 <br />i� /,JC, <br />City: Z-40191 Zip: L <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 />T niK S Tuaccepting tank and/or piping. G a <br />FacilityName: �/¢2�� //•. �� =/ ��v<©/�c6��� .r" <br />Address: LZ�2 .� // ��i City: / i Zip:_9J J3� <br />Phone #: ( 2125, q Z <br />Date Tank <br />Name: Title: Signature: <br />Date <br />TEL 1 irynid ,-0 <br />AvJrZtss <br />(3 _ 1'iaaje Xf <br />ric3t ^'6L9SS <br />EH 23 046 <br />S GN A)1 TZ A /Z STs- L PRO J ✓ G %S <br />/ <br />"20- rOGSvI�07 iZ040 i2An9CNr� C�,2Jcrdi¢ <br />(`7i6)y£iS 4twly <br />To rORi 4al,) /-le-, - <br />,40v11Es 5 9 9 9 9 s, 4&1s r..,1 <br />,46 -4 (Zvq <br />9 .�)_ 7y -L <br />