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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> 2 of 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:_Ai,A Q b 5 g 5 <br /> FACILITY ADDRESS: Whn ` pro ate' <br /> TANK ID#39 4_*(A hi L TANK SIZE: I Z, o oy PREVIOUS TANK CONTENTS:Uih4m,10 &Aj bL AE <br /> *********************************************************************************************************** <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: PO.a wbasU MT.LA&M I L&L 1 N C- <br /> Address: 1 1.t)n W iluak S s,rrs,� City:SAk LIA4Lu2" Zip: °J 4 67 7 <br /> Phone#:(SI b ) G.l 4-Tk3 LK 1 D3 Date Tank Removed: <br /> *********************************************************************************************************** <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 /> *********************************************************************************************************** <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 /> ********************************************************************************************************* <br /> EH 23 046 (Revised 10/16/03) Page 10 <br />