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.7-1'4560015 TAIT and ASSOCIATr-" <br />V - 07 p.m. 11-28-2006 3/3 <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 I — 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 <br />completed and returned.. / <br />FACILITYNAME: /","/ <br />GO +rtj jp[ jj <br />FACMITY ADDRESS: / 3 p 6d t S 0 vt W y `7�U��—Ur! f pct <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 />Address: �4 -x !3! V ii City: 1?_jC_4 10 "j2 Zip: - 41 b-0/ <br />Phone #: s( I C) 3 ��l �i Date Tank Removed: <br />xxx*x**xxx*******x********xxxxxxxxx**x*x*xxxxxxxxxxxxxxx�xxxxxxxxx�xxx«:exx*xxx�x�xxxxx*xxx�exxxxxxxxxxxxx*�x� <br />SECTION 3 - To be filled out by contractor "decontaminating hwk": 1 PC <br />Tank Decontamination Contractor: G Lf <br />Address: Z 5— tDW24 . 131 U 1�) City: JZIr�✓190N i� Zip: 9414-01 <br />Phone #: (5-1 O ) Z? F— t 3� 95 <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 />xx***xxxrxxxxxxxxxxxxx*xx**xxx******xxxx*x************x**x**x****xx*xx*x**xxxxx*********xx*x*xxx**x****xx** <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 />Address: Z SS �i}✓L?l< z� !3L UIQ City: %Z t ✓Y1 O ✓� (� Zip: 9 y $ D l <br />Phone #:( [ D 1 23-r,-- <br />Date Tank Received: <br />Name: Title: Signature: Date. <br />*xxxxxxxx*xxx**x****xxxx*x***xx*x******x******xx**x**x*x**xx**xx**xxxx**x***************x***xxxxxxxxx**** <br />EH 23 046 (Revised 8/9/06) 10 <br />