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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ##**#*#****#*####**########***######***#**#*##*#**####****###****###**##*##*#**#*#**#####*######*#*#*##**** <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 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 completed <br /> and returned. <br /> FACILITY NAME: l I 5 ked <br /> FACILITY ADDRESS: -7 7e)D Pktp*r?-LG n �irfi <br /> 1341'14-� '" /?+'tvaa uN brat/eco 945 <br /> TANK ID#39-(%j-q0 - 1✓1 TANK SIZE: ��id4b PREVIOUS TANK CONTENTS: p(�y t136%1 4f 0 o <br /> l7 PG►til 1�'^"') <br /> C}L <br /> SECTION 2-To be filled out by tank removal contractor: / <br /> Tank Removal Contractor: P4✓4d I f 7 M e4ACt^1tL41 <br /> Address: R. D, ag2X City: yQH 4_t4�110 Zip: <br /> Phone#: Date Tank Removed: <br /> #*##########**#####*##*#**#####*#**####*#****###*#***##*##**####*#*####******##########**##**#**######*#**# <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone#: <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: Title: Signature: Date <br /> *###***##*##*#**#*####*#*#***#####***####***##**####****#####***###***#*####*#####*#**##****####*#*######## <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. <br /> Facility Name: <br /> Address: City: Zip: <br /> Phone#: � ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/16/03) Page 10 <br />