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17 <br /> _ y %0' .37 <br /> i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 46&3420 Fax: (209) 46&3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION t — 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: X71 7 <br /> FACILITY ADDRESS: <br /> � � 7 Cf , � T <br /> TANK ID #30 - Qt_"'—[J=t, TANK SIZE: ` 0 Q ' PREVIOUS TANK CONTENTS:,,a3 2Z .,.SCD !J GAS <br /> +wxwwwwwwwwww*wwwwwwwww,�wwrwwe*www*www�x,ri,cow:c-aws****w.x*wxw** x-:r,�-kw:r*w:rwww,�-k**wrwxw,taww,t*,twyrw**wsw#wwwwww <br /> SECTION 2 - To be filled out <br /> -byytank removal contractor. <br /> Tank Removal Contractor. �Q4j � ��G ��✓� /� <br /> Address:_/� D D cam. -3�,] City:_ - Zfip: dL- - - <br /> Phone #: (. 1 _� Z �J ��i DataTankRemoved: <br /> wwwww,i.,t,rwwwwwwwwwwwwwwwwwwwwwwww,itw,twwwwwwww+wwwww*cow*wwwwwwwwwwww*wwwwwww,ewwwwwwwwwwwwwwwwwwwwwxwwwwxw;c <br /> SECTION 3 - To be filled out by contrac�torr /"decontaminatingaing tankk": <br /> - <br /> Tank Decontamination Contractor.=/ zz / (J'/j! f ®l� /�V4C - <br /> Address: P4 Q /J 7 City: G- 1/2 Zip: <br /> Phone #: � LEI <br /> Authorized representative of contractor certifying through signature below that the tank has bee laminated in an approved <br /> manner aassyrequired <br /> dbbyy Cal EPA. <br /> NamaA///�7 /� / QGTitle: �D� 04Slgna4ure: ; ale <br /> wxwwwwww,twwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwww;tiwwwwwwwwwawwwwwwwwwwww*wwwwwwwwwwwwewwxwwwwwwwwwwwwwwxwwwrx:r <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:- _ ✓ �` ✓/ Tz�� � S ( � � �`j0� c(G7S' <br /> Address:- l � e/ itgt: Z City: chrCG . Zip: <br /> Phone #: aecalve& <br /> DateTan /� <br /> Name: 1 r3h ,, 0 Al,, rdaltle; I�✓� G � �F � Slgnature, /7 Date <br /> EH 23 046 (Revised 8/1/11 ) 9 <br />