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Jul. 22. 2013 9, OOAM No. 4153 P. 2 <br /> ��4 L <br /> ENVIRONMENTAL NTAL, HEAL T]a DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> TelopYtones {209)468-3420 rftx., (209)468 3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> frit.tttAfli At.trlttlfaff.tiaflf.tftttf.fl..tA I traf*At ra./14ttttltaftf k..**&A t[tft*t P.at fa.1....t*at.tff Y.A <br /> SECTION 1 — SJC Environmental Health Doparimonl's Tank Tracking Shoot Mail aocompnny each tank afilxed with Ila site <br /> Idonliftcatlon number. Tho Tank 'Tracking Shoot Is to ba rolurnod to the Environmental Hoolth Department vvlthln 30 cfavof <br /> ncceptance of the tank by the dlspooal or recycling facility. The pormlt holder Is responsible for ensuring that this form Is completed <br /> and returned. <br /> FACILITY NAMC:��lrre� <br /> el <br /> _ L <br /> FACILITY ADDRES �7 � S 2 <br /> TANK ID#39-*L � '80,,ZO 949 n r — <br /> PREVIOUS TANK CONTENTS:. <br /> k1F1'**kkX**d***##Yrk**!t k:t#*kh*R###RA*#iC*Y**#wW+cv�**A*3it*#RA*w*�rxx�r##****k•kik Ric k*K�**Ycwvw*#-Yx'iE�w+kftkkwxnk*+Ywwxr <br /> SECTION 2-To ho filled out by tank removal aonfroator: <br /> Tank Removal Contractor:, ��,�l�rr� /'p� Z Y <br /> Address:�i� /fes�//�. .Scta l city: S{Y rY10 ztp: <br /> Phone#:t I& wo Date Tank Removed: <br /> *****3:*#7;'k**WYYrR#vkY��4yt4k fkww w*ww ww w**vr**wwwawww*wwww frwf4+Y*9tww4xwfv*wieitw,PwfF#ww+xaelrw�www�rfV wivwykwYnRaQ�Y(w*srxwfkw k <br /> s5cuoN 3-To be filled out by oonlraottor/"decontaminating tank": <br /> Tank Decontamination Contractor.' 04 4' <br /> Address: ye-IC /s Al, ,, t' y <br /> Phone 1l:('3/� �'2-2 zl,11-30 <br /> Aulhorized representative of contractor certifying through signature below that lthe tank has been d000ntomfna(ed in on approved <br /> manner a required by Calf PA, <br /> Mama: •h Lt ivy Title: Signature: Dale 0�` J <br /> I trUTA w****0,htA.A0 A P.A At4Anh*kx•x*w•lk**'k* ************-iiL** lurk*sFx+k******rc****ww******,k,w***w*w <br /> SECTION 4-To be signed and dated by an autborized reproeentative of the treatmenl,storage,or disposal facility <br /> accepting tank and/or piping. <br /> Facility Namer �� /�S �J�r�l /y G� J /Z- <br /> Address: Z,-Jee ? CI Ey:6gl&r _ 7Jp: I fLll Z <br /> Phonait:(ei v 351 KIJ _ <br /> Date Tank Recolved: <br /> Name: Lb:i2 -Pile:, kW%1Rf Slghatura: Date Z <br /> EM23046 (Revised 10/30/12) 9 <br />