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ENviRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUTN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) -468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> *#*##MM#*MM#*#MMM*####MM#MMMM*M##MMM#**#MMM**##****#M#M#MMM**MM****#MMM**MMM#*######**MMM###M*MM******MMM** <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 <br /> -- - -- completed and returned. r e<: BIZZ ) RRI Z9 (FST-9TH �^1 d�Sy��-✓7"S <br /> FACIL TYNAME:_04041ElZ /YloJ ^,� //,fc(' J / L_ O T <br /> -- FACILITY ADDRESS: CL1 „s • �G /�� �,g / <br /> TANK ID #39 Z6 TANK SIZE:/ /ZI5 PREVIOUS TANK CONTENTS: <br /> #*##MMM#***#####***##MM##**#MMM**M##M#M**MM#**MMM##*#*M#**MM****MMM**#**M##**#MM*M*#*MMMM##MM#MMMM#M*}MMMM* <br /> SECTION 2 - To be filled out by tank removal.contractor: <br /> Tank Removal Contractor: ole, 144, . <br /> Address: h O D X t 3 Ci Gil/� <br /> I ty: Zip: <br /> Phone #: ( 2 ) _ L / 7 �O / Date Tank Removed: <br /> MMM***#MMMMM#*##MM#M##MM#M##*MMM#***MMM####M####M*##*MMM##MMM*##*MMM##*MMMM#**#MMMM##MMMMM###MMMM#M##*##M## <br /> SECTION 3 - To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination Contractor: ✓70e),7 /�/G <br /> Address: �� iC� t7 �C `� ,5 / City: LoD I 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 /> Namc1 jrT1y 71rm?�L Title:CAQn2110CT(J/Z Signature: Date ' <br /> #**###MMMMM*#*#MMM**#MMM***MMM****MMMMM***MM#*#MMM*#*M**#*MMMM**M M ***# MM#*# MMMMM*##M#MM#MM#*#*##MMMM#* <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatmen - storag , or disposal facility <br /> __'accepting tank and/or piping. - <br /> Facility Name:_ S L 17� 0ezZ S7eeZ ?o/7Gic <br /> 14E:�OZ 50,91 -3 .e City: COR 0OV4 Zip: C7 7_ 7 �� <br /> - Phone #: <br /> —Date-Tank-Received: tD "l OZ e <br /> Name: 'y e sF/- (,.:,{ k .`-t«z.iy Title: Signature: :Date ' f G`'- <br /> MMMMM****##M#M#MMM**#*MM***MMM**###MMM#MM***MMM**#MM*#M#**MM***# #**MM#M*#MMMMM***#####M#M*##*#*###MMM#*# <br /> EH 23 046 (Revised 12/31/07) 10 <br />