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Feb . E . 2005 2 : 31PM • • No- 3449 P . 10 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> .!lwrprlw•rWkrr Wr•rrrwrk M•»W+MMrwwr+*Y4r.rrrww <br /> SECTION I-SIC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site Y44Wk <br /> identification number, The Tank Tracking Sheet is to be returned to the Environmental Health Department glthin 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 NAME: 11) C�. <br /> J v <br /> FACILITY ADDRESS: <br /> ' TANK ID#39-_&5 _L30 I TANK SIZE: -7 SD qw <br /> PREVIOUS TANK CONTENTS;_ W l p t <br /> «4rwkl YYwrk!«WWrkY4rk»k4Ybk44r4rbr»krrwrgr4r4Wk4444r4r4WW4r4wM4rk44Y4k 1w444kYw4r4 <br /> SECTION 2- To be filled out b +WWkk«4»ikklk4Yk4!»MWk <br /> y tank removal contractor: <br /> Tank Removal Contractor. 1� � � <br /> ' Address: 03 0 34 6 <br /> Cltys L o N (!)A <br /> ZiP:�S_ <br /> Phone#: O q ��{�, l aq Date Tank Removed:— / \- <br /> rq»r•t ! -a V � — <br /> WW4WksrwrW4W»WW.kk»rWW4«krWk»Wrsk4rw•4WrW4Wrw»wrr4Ww Wrk Yw Ww4wrWWk <br /> SECTION 3-To be filled outby contractor"d "•'•+•••••+r4wkYw4kklr»r••rr»r.r <br /> econtaminating took": <br /> ' Tank Decontamination Contractor. <br /> N <br /> Address: -t pp pp / S U t2 <br /> Phone#: L �� "(0 ' City: w}} ip: Vi °I U <br /> Authorizedrepresentativeby Ce E contractor certifying throng signature below that the tank has been decontamioamd in an approved <br /> manner as required tb^^y Cal EPA, <br /> Nanre:,h t ,j t_ Fn rw KI,. ^ <br /> Tide:_ pptf Sigaatu <br /> 11 Date l2-ag—Oy <br /> 4Wrrr4YY!»W44Wlr4WwRkr4r•4r»Wk4 <br /> r4wbNMMk4!»wWl•rbYrk rr»r•!R»r4•!wY••♦•»»wrN•rMMNWW!!!w•rN«rrwrr»rM w«M• <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tank and/or piping. <br /> ' Facility Name: <br /> e � V <br /> Address: <br /> ' Cid V*N zip: 9.` 66 Z _— <br /> Phone <br /> Date Tank Received:. <br /> Name: Title: <br /> Signature: Date <br /> 4WWWkY4w4W brrW4f WrYWw.r»4W44Y4r H4r»W4Y4 W»W kW4»r44w44r<k W44M+w444ksk WrWkw4»4wk _—•`—`— <br /> EH 23 046 (Revised 10/16/03) 4Wwr•44kr•44 Y»r44444w»rk4 <br /> Page 10 <br />