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i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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 returned to the Environmental Health Department within a0 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:_ <br /> FACILITY ADDRESS: 7/ � . T C <br /> TANK ID #4g —_TANK SIZE:�_PREVIOUS TANK CONTENTS: f,�l .�jCQ • L) <br /> W**W**W**#**w***Www*W*www#Ww#ww**w#*w*Ww#**#****w***Ww*#***##*ar******w*********************#*#*****Ww*** <br /> SECTION 2 - To be filled out bbytank removal <br /> contractor. <br /> Tank Removal Contractor �j`_ �//YJ / © VOCL <br /> / n <br /> Address: D � � City: lJ/J � Zip: dL <br /> . Phone #. (212-9J--2 Z �/ 5 Date Tank Removed:_ 16�— ; <br /> SECTION 3 - To be filled out by contrac "decontaminating tank": <br /> Tank Decontamination Contractor._ J //y/ / /�©/(Pf <br /> Address: l" !1 / <br /> (3 /J > <br /> {—`, Zip: 7� SL/ <br /> Phone #: � _ , � ..Z /' s Ell <br /> Authorized representative of contractor certifying through signature below that the tank has be <br /> manner in an approved <br /> manner as required by Cal EPA. <br /> D <br /> ? Ti <br /> Nam5e04 �Title: n) l✓t�CT/t Signature: • f ate // <br /> / <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting <br /> gttank and/or piping, A y' <br /> Facility Name:_,�c—/jlf1J� TZ�� � ` S / �O eE� � cl 7c <br /> Address: 2.O l CJ� SL`JGY/ �/I/�� City: tJ�� . Zip: <br /> Phone #: aecelved., <br /> /s/l��jr � CJ <br /> Date Tank �7` -2 <br /> Name: l /nsi L A J108: de24d, n, .F :_t . <br /> Slgnature /7 __Date p) A <br /> EH 23 046 (Revised 8/1/11 ) 9 <br />