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VTI? I R001%?l�ENT EAL DEP A I MENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 ensuringthatthis form is <br /> completed and returned, � e/ slLL/ f <br /> FACILITY NAME:_ 0604)E (Z �✓,/37' //+ j /C IL N <br /> FACILITY ADDRESS: , 2 J S • �G /�� 1 /J <br /> TANKID #39 - OSt TANK SIZE: 20 0 PREVIOUS TANK CONTENTS:�st�� <br /> SECTION 2 - To be filled out by tank removal-contractor: -- - -_-__ <br /> Tank Removal Contractor: � / ewYl -/yp� 69c <br /> Address: l� O X r13 Jr) 7 City: G�° /� / zip: a.5:► <br /> Phone #: (,� �)i j Z. C/ 7 "/ / Date Tank Removed:_ /0 7X10 - - <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination ..1/ioContractor: '7/yJ �j j/Q/2��' �/ G <br /> Address: �� 6oX / City: ZI9y Zip: <br /> Phone #: <br /> Authorized representative of contractor certifying through signature below that the f been decontaminated in an approved <br /> manner as required by Cal EPA, a <br /> Name:////9/Z71&4 //S�O/C ` --�� / <br /> /� Title:l JA �ltif G7024 Signature: Date / <br /> SECTION 4 - To be signed and dated by an authorized representative of the trea ent, storage, or disoosal facility <br /> accepting tank and/or piping, - <br /> FacilityName: 3c— W J TZ ✓ j <br /> City: COR dw4i Zip: <br /> p - - <br /> - . Phone. #: ( % D 5/ -`/L� O .�� - - <br /> _._D7mecciv,,**., <br /> NC.. OLLI 1 a Title: ( A�CLoq -A' '��� Signature: Date- /dam /l"7CJ <br /> EH23 046 (Revised 12/31/07) 10 <br />