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SAN JOAQUIN COUNTY <br /> ENVIRONMENTA)<..HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> 1 01F 3 <br /> #*#*#+##+##++######*###*###*#+#####*###***#+*#####+#*+*###+###++**##**##++**##++++##**+*##*#**++#++##****## <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: AR-r-u 4k 0 0 S 9 !5 <br /> FACILITY ADDRESS: &10 Uij uwao G S io4Jaorl CaA <br /> TANK ID#39- j pAW i TANK SIZE:j bo m&, PREVIOUS TANK CONTENTS:UAL&tA9 QseL1NE <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: P4R.&b4n ►N c. <br /> Address:�(,p o w,L Lj i Mc 9TCAir CitySAA 4AAD" C-A Zip:q kt577 <br /> Phone#: (51 V 0 rM.. 103 Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone#: <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 /> accepting tank and/or piping. <br /> Facility Name: <br /> Address: City: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/16/03) Page 10 <br />