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ENVIRONMENTAL HEALTH DEPARTNMl T016 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 HCAITU r"C OTA"C"'- <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 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: 7- <br /> FACILITY <br /> ,��c 7 <br /> FACILITY ADDRESS: <br /> TANK ID#39- TANK SIZE: <br /> 5_t5 / PREVIOUS TANK CONTENTS: <br /> SECTION 2-To be filled out by tank removal contractor. <br /> Tank Removal Contractor: ,(.J/ <br /> Address: /�' o �� /` City: Zip: <br /> Phone#: Z) �LC-6Z Z > Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address' 4 r 0 G � 7 City' C� %� Zip: C2� �L <br /> Phone#: ( 20'9 ) <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: �����C�f�< < Signature: Date <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: ���fyllZ��� S��' � � r7G'JvCTs' <br /> Address: L_ � city: f / U <br /> 5 %G�— / J l � 04v� Zip: � <br /> Phone#: (11� <br /> (� Date Tank Received: <br /> /( Name: Title: Signature: Date <br /> EH 23 046 (Revised 12/10/2015) 9 <br />