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L <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 NAME I AA IZ IS P G th'1 A (;)i 11^1 "r6 Y? C Los o "LE Ohl LY <br />FACILITY ADDRESS: <br />TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor. <br />Phone #: <br />Date Tank <br />SECTION 3 - To be filled out by contractor "decontaminating tank': - <br />Tank Decontamination Contractor. <br />City: zip -MAR a k 2017 <br />Phone #. f—� <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: Title: Signature: Date <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />ac eptina tank/��tandfor Dioinq. <br />Facility Name: td/A <br />City: Zip: <br />Phone <br />Date Tank <br />EH 23 046 (Revised 726/2016) 9 <br />