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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> 3 of 3 <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 # ohs 9 5 <br /> FACILITY ADDRESS: �.l 14,6.t.►wAl 99 1_-T o&k-Ai)11 , <br /> TANK ID#39-p SEM j to TANK SIZE: 11l o b t) PREVIOUS TANK CONTENTS:Vwj&bw 6As o(_j titf_ <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Q A2d n�s u MfcGL1 k Lit(.�L 1 N L <br /> Address: 7 (,0 o S Citys" t ie ab" Zip: 014,577 <br /> Phone#: ( 1 o )(A Y -5131 D rxI o 3 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 />