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9 <br />, E+ 1'dVIR0. NMENTAL FTEALTH DEPARTM, ENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 — SIC 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 cf <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. - <br /> - _ �/�.B/LL �,J ,P�9L- QST T� /.,1d�Sy�r�,✓�"f <br /> FA-CII,ITY NAME: /Y//n) G �- /./'i3lr..a.J LOT <br /> - - - FACIIITYADDRESS: .22 S� Eel <br /> TANK ID #39 - CfSTANK Ste: .4000 " PREVIOUS TANK CONTENTS;��Jk <br /> SECTION 2 - To be tilled out by tank removal contractor: - <br /> Tank Removal Contractor: Q/ G /,I)G <br /> Address: P O `L3D )ce i 3 S 7G/v� / <br /> Ctty: Zip: <br /> Phone #: (; )yj z �/ 7 / � � Date-Tank Removed:-- /0 7 �- /O - - <br /> SECTION 3 - To be filled out by contra—cttoorr "decontamihating tank" : <br /> Tank Decontamination Contractor:- <br /> Address:- & tU ox/ 3 7 - City: LVy I ZiP; 2 <br /> Phone #: ( 209) . 3 Z9Sn�tz <br /> Authorized representative of contractor certifying through signature below that the tank aas been cont 'nated in an approved <br /> manner as required by Cal EPA. - s a <br /> 7,'/P <br /> � yr�� /�/moi <br /> fJ2 Signature: Date /C/ '" J / I/ <br /> r' <br /> SECTION4 - Tobe signed and dated by an authorized representative ofthe tceatm f, stor ge, or disposal facility <br /> —accepting tank and/or piping. <br /> - Facility Name: SN <br /> _-- address: <br /> --- - <br /> city: cp/t dW4 Zip: L ! 7 7 z <br /> Date Tank Received: / 0 / <br /> - Name: - lrS(-f' (-vtd. a Title: Signature:Signature: Z Date - Is <br /> EH 23 046 (Revised 12/31/07) 10 <br />