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1 <br /> ENVIRONMENTAL HEALTITT DEPARTMENT <br /> SAN JOA_QWN COUNTY <br /> Telephone: (209) 46&3420 Fait: (209) 46&3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - 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. (ES/91 ;2� /���5��f£��•f <br /> 1 FACILITY NAME: 0"05IZ <br /> _ FACILUYADDRESS: <br /> TANK ID #39 -QE1I R (, TANK SIZE: PREVIOUS TANK CONTENTS:��J/� <br /> SECTION 2 - To be filled out by tank removal contractor:- <br /> Tank Removal Contractor: \JY.��I /�f(fop j'�� 0/ e. <br /> Address: �1� O !3 0 r SGS 7 city: GOy/D, / a� zip: a5:04 2 / <br /> Phone #: ( r <br /> !i -v�l�j Z 7 S O I Kato T:attkgt�moVe'd ` 0 ' / /0 <br /> SECTION 3 - To be filled out by contractor <br /> � contracttor "decontaminating tank" : <br /> Tank Decontamination Contractor ;0;701 <br /> 6/ Z <br /> Address: UDCCit : � <br /> V zip: Z <br /> Phone #: <br /> Authorized representative of contractor certifying through signature below that the tank has been dec ntami ted in an approved <br /> manner as required by Cal EPA. - - <br /> Name �/�/z�/.✓ �D/Z?� Title:aQw; 1fG Z.� —t� / L✓ <br /> �Sg?treatmf <br /> = ate- <br /> SECTION 4 - To be signed and dated by an authorized representative ofag , or disposal facility <br /> acce�gtank and/or piping. <br /> Facility Name: <br /> - - Address: APL <br /> � City:_ Cotqdcaol Zip: 5 <br /> / 7 <br /> / <br /> -.Date Tank�Recewedf d d Id / <br /> Name; ° Ci ll,.Ycvbb 444 a 9g , r <br /> EH 23 046 (Revised 12/31/07) 10 <br /> 9 <br />