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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> A" <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> .r..••+•s•.•n•rrr•rt rtf rrtfrtw•••••r•rrMMMMMrW#w+rtw•rarMrt Mrt#WYtw Mr W.+r#Mr#w#r+Wrr••••r•frMM+rrtrt•rr+Mr rrr••r <br /> SECTION I - S!C 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 <br /> completed and returned. <br /> FACILITY NAN E:� <br /> FACILITY ADDRESS:71)D <br /> TANK ID 939• TANK StZE: `PREVIOUS TANK CONTENTS: rs� <br /> ••r•.t•••.•.••Mr Mw Wr}f Yr r+•/W'••++!/MMM++#WWYf rtW•rMMW}#Yrw rWrW#rr}rwwwwwtMMr#M#}W ftrtYYr Y#+MtMf WWWwttrrrtwrtfM <br /> SECTION 2-To be filled out b1removal contractor: <br /> Tank Removal Contractor:, -, C SL <br /> Address: � 9, u L4 )-n_ �27, pCity;s:5M�/ rVA)l Zip; "�� <br /> q d rem <br /> Phone N: _(}� -a.. 5-7jDate � : IR t I [ " o Qi�- �l <br /> rr.r.tt.•.+r+4rtfwirtf Mr.••rr++M++WrwWrrt••rrr+Mrtrlrt;lt Mr • '411 t+rwf•f•MMY#wttirrrt•Mrtrtrtrrw}###s••MrtYrtrYf MM}#rr• <br /> SECTION 3 -To be filled out by contractor"decontaminating <br /> Tank Decontamination Contractor.prt X212 oz bQ e2 <br /> Address:-4 j / —�L4111 it Cih�Zip:�S JSr� <br /> Phone H: 1-j --S—&T-3 <br /> Authorized representative of contractor certifying through signature belowa e has n aced in an approved <br /> manner as required by Cal EPA. <br /> Na n�l � OTitte: ignaltu Date <br /> .•••+#+#••t•iMMM}}rtrtrt MWYettr MMMW4wtYYwwM#MM}tit#ww#MMM##YtYYYYWM}t}ttw#f tM•#trwYwrr#t#MRM##rr###rt#YYt•Mtrr+- <br /> SECTION 4-To be signed aquwmokanauthorized representative of the treatment,storage,or disposal facility <br /> accepting tank an or pipin�g� <br /> FacilitylNa V - OCL/' c,7Fi✓tc..t/tCZ'. G� <br /> Address;�� �[ - uk, Ip,t) t-j� City- ' jG `Zip: <br /> Phone H: 2 v <br /> Date Ta tk <br /> Namc: lLpp�' Title_ 1�/�.inrxr S[gn pete_�t <br /> •••M.••••rrrrWtrtt•r•rfMMM}+#rtrr Mr MM##t wf#MMM+}rttY♦rrrt#rt}#ttY##rrtrw WM#Mt#itMt+#}rtrtrfrtrt•+#wrrf•MWtw•••rt <br /> EH 23 046 (Revised 11131/07) 10 <br />