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- <br /> u _ . <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 retained to the Environmental Health Department within 30 days of <br /> acceptance of the tank by the disposal. or recycling facility. The permit holder isresponsiblefor ensuring that this form is <br /> . _. completed and returned. �G 72�LL/�1 , JW' SST ;2� /�Jd€Sy�/F-✓�`� <br /> FACILITY NAME: /YII.j 4 IL pp A //iRr-�J j Lo T <br /> :__,._..... - . <br /> FACIL ITY ADDRESS: „2I S�- S • GG /�O/c. I Q _ . <br /> TANK ID #39 - OYJ�? [_TANK SIZE;-.5 S50 PREVIOUS TANK CONTENTS: <br /> SECTION 2 - Tobefilled out by tankremovalcontractor:. <br /> Tank Removal Contractor: Ole, z4G - <br /> Address: l� O L3 o/�.Y S 7 city: Z'01D / zip: <br /> Phone #: (6 i �3Z / Sok'/ Date Tank Removed:_ <br /> SECTION 3 - To be filled out by contraactor "decontaminating tank" : - - <br /> Tank DecontaminationCo`nttractor: <br /> Address: �� QO ,C, /J 7 City: L41919 I Zip: <br /> Phone #: .( '11 <br /> Authorized representativeof contractor certifying through signature below that the t been decont 'nated in an approved <br /> manner as required by Cal EPA. � - <br /> Namei�/z�/ ✓ /ffOK/�� <br /> Ti <br /> - Signature: sposl <br /> Date <br /> SECTION 4 - To be signed and dated by an authorized representative of the treat m. storage, or disposal facility <br /> epting tank and/or piping. <br /> --- Facility Name: S �/s� Z 7Z 41 S <br /> __ dmess;— City: COR dCV4 Zip: <br /> Date-TaEtlFRcccwed/:'_ 1 X/ <br /> Name" 4 L..aA• .� F3aS Title: Signature:- - Date /j <br /> EH 23046 (Revised 1201107) 10 <br />