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ENVIRONMENTAL HEALTH DEPARTMENT, <br /> SAN J OAQUIN COUNTY <br /> Telephone: (209)4GS-342(1 Fax: (209)4CS-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> 'k i'•kW%W'l'iW AAW i'A'-1'.1"h'k *A''IW WIAI YA"F'A'1A Ik 'IA'1%A't'k'A•4'A'I"i'W%'-1'k%IWkAW'A'W'k i k'l'i'k k1•ki'a W'A'kW4'KI.**.kk'AYf'hW A"kYf"k Wf•h'hl%Yl <br /> SECTION t - SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with Its site <br /> Identification number. The Tank Tacking Sheet Is to he returned to the Environmental Health Department within 34 days of <br /> acceptance of the tank bythe disposal or recycling facility. The permit holder Is responsible for ensuring that this form Is completed <br /> and returned. <br /> FAC IL I•TY NAME: <br /> FACILn <br /> Mf ADDRESS: ssD w � G-U� 1 6yj <br /> 0152 a3 D T R — <br /> TANK D#39- „?/ .I TANKS LTE: PREV IOUS TANK CONTENTS: ��esc l G�tSp I r n <br /> �C'+f<TlC S'TlC'.C'lCx TQC^C'll"T.FTX'if YCT:CST]CX'iC'!CY"T:CT T.'iCX:C iCX::'T T"ICT'J•.'T'X'C'+C:c^CT�cTX"�("IC:CS'TJCTCTY TT'ICJC Tf:CJC».T7XT:F��C?C'KT'iCTY�C7f f�f lC:t JC�C'ic fK�TT)C ICAC;C is ' <br /> SECTION 2-To be filled out by tank removal contractor: , � <br /> Tank Removal Contractor: k0tnM 0. � SOnS t/on ��l ct `o(\ -_T n e� _ <br /> Address: 1"•C)• '(�Uy %1iD3 City: Zip: <br /> Phone#: ') s����, Date Tank Removed: <br /> :�'�'r.1F]C YiCTTG'�C]CTFt:YXCICTFF%'T�i'�TTTi{TFZ'TTTS!".f\lC.\:CSC T•,c(T'>::TT�[1CT:FTTx7CC 1'xT'T<'%C'fCTt'S"F�TT'FTY`iit•T'iC['"%'T�CZ':TSK T)f 1CTTF�i'�C C St"<TT7CX <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: ad,aa\5 Xo" I _Z-1 G — <br /> Address: V gb monim a'd City: Cf Zip: `7702-10 -_ <br /> Phone#:( 31) L/g30 --- <br /> Authori_ed representative of contractor certifying through signature belowthat the tank has h en decontar nated in an approved <br /> manner as required by Cal EPA. <br /> Name: W*e_46tle:�ff°�i(QQ,f1 _ Signature: --Datej Ll <br /> 'if'C:!^.0 SCX:f:C IC:C:C SC'lC:C:CYX'ic%lf`f^C%ff lf^.[:C<'.CXX]t'Y'1f T':CTFX:C:C'iC:C%7['if:CXSC'iC if>C if:f Y%iC if iC'ifXYF)C if:<:t i'Y%'%ClfTXX`C'if x'If:C:C:fx Y:ifXT:CX]f'if Y:<T'^%�f 1C:C:f:i•'2-% <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage.or disposal facillty <br /> accepting tank and/or piping. i ��/1 <br /> Facility Name: Q (SCD Q6apGadlJ <br /> Address:� i2r's Cn City: . (0t?/_M0J_e Zi p: <br /> Phone#:( q� ) �!� 6 <br /> i <br /> Date Tank Received: <br /> Name: Ttle: Signature: Date <br />