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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JO aQUIN COUNTY <br /> Telephone: (209) 468-3-120 Fax: (21:19)468-3-133 <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 Enmronmental 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 completed <br /> and returned. <br /> FACILm'NAME: EC-co PtM j PA (� —_— <br /> FAC IL MY ADDRESS: SSC .` 7, \)n Qp C) Rd C/1 <br /> -rq off' bo <br /> TANK D#39- TANK S ISE: PREV IOUS TANK CONTENTS: G esc 1 (>ztSol n Q <br /> xxTTxsx-�;xT�xxxxtz-..�xTT..Tfx�xtxTrx,x..-..x<x,��xxx,�txxx>xx�;xtrxR;:-xz,:xx,s��x;,�-�xr;Rx�,�«-�xRtx�s:x��rxxxxx<� <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: t>1�ey-\AA- c0.�� y� S S (/ <br /> f" n a7n2horsJ fn <br /> Address: ?C). )11-i 0 3 City: p: S <br /> Phone#: _ Date Tank Removed: — <br /> T a"I.t'F xR'FxT.c N'A'T'T'F T'!c F'.`T7C it x C'lC�FI[lC![FTT'xr'iC�':C lT'.TT[?CR.'F 4'ic R'iC lcN�':t'iC TF'iFx�t'iC lCx t tF:ix cictr'T T'iFt%ic.c T'.CTCF rx xxcSx tx xtt'F cc xT�:tf'�x x <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: tt /I,, C� <br /> Address: ���(� � 81 1410n,)% JC') City: ('l101,;1 f\04 Zip: <`0yIfe <br /> Phone#: ( 5121 - 4q)191 — <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Ttle: Signature: _Date _— <br /> xT«-x.ctxx:r-,r+cxxNNN NNNzNxNxNNN:FT:NN:<NrrNNNNir:eN NNNNiriNNN Nxictxti-�rNNNNNNNN NtNNi NNNN Nx-,rxxNNNNxn-t-.eNirx NT-NNNNTr T•N:FNN <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, storage. or disposal facility <br /> accepting tank and/or piping. r <br /> Facility Name: V QSCD i2oo P )-Q✓1 `J7�J <br /> Address: /��(�I �� ,-,S co Lod City: L I Q/ A►t4`e zip: <br /> Phone#: <br /> Date Tank Received: -- <br /> Name: Ttle: Signature: Date <br />