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! 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 to <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />„ <br />....... <br />..........,.,.,.... <br />......,...,......... ........, , , <br />SECTION 1 – SJC Environmental Health Department's Tank Tracking Sheet shall* <br />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 ays of <br />d <br />mit holder is responsible for ensuring that this form i <br />acceptance of the tank by the disposal or recycling facility. The permit <br />completed <br />and returned. <br />FACILITY <br />FACILITY <br />TANK ID #39 - TANK SIZE: //_6 PREVIOUS TANK <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor 1 177 /.c/, <br />Address: <br />City:_ L i>/_ /__Zip—�S <br />Phone #: %mil ,j�j�(p�75 <br />Date Tank Removed' <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank DecontaminationContractor. i/h •%%!d /Z t�� tf%/ /.jG <br />Address: SOX 3 -4-1;7 City: ZOO/ Zip: C/ S L 7/ <br />Phone #: (aeel l 3 46k,�-,/ 7< <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 />NameNT,� itle:l/0 <br />01702 Signature: n,re <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />%A JK S accepting tank and/or piping. <br />Tu <br />Facility .. h j- n i / n ♦ ,I. � '1 . <br />Address:_. <br />Phone #: ( Z V <br />Date Tank Recei <br />57__-:-tL (�i�/n1� >O <br />Iolm4 s5 <br />P�lO.JE st <br />/moi/'i,✓d �,� 9 '� � <br />d'o W– <br />lr <br />city:. �FnJ� Z;p:L33F <br />Title: Signature: Date <br />.5 ch Nr Tz c /Z Sri L PRO 1) ✓ c 7-5 <br />/"00 <br />00 rOGS01507 fZe)4) 'Z fj6RJ <br />(g16)78,S•-5�ri <br />