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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 46)8-3420 Fax: (209) 468-3433 <br /> F: r. V t3 L <br /> UNDERGROUND DISPOSITION TRACKING RT�CORD <br /> •.*t*irr#Y#•#wrr«•M*lir*i#r*s#ti#rwi.iri*riiir***!i*###t#ri#iiwii**ilii*#tM***wt* •#i***iw*rirwr*.#twi.irrt <br /> SECTION I - 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 <br /> completed and returned. <br /> FAC[LlTY NA-T: 6P ZA K t:o # ZD <br /> FACILTT`r• ADDRESS: d e- v e m%A QVt�e �0. C qS 3 3 <br /> q :i(vPCONTENT TANK ID#39 SIZE: 10�a_PREVIOUS S t•1VA��2c� <br /> Q,pc V OG. ^ <br /> *.r•.ti***iiiiriis*sis«i•#r�+#.M irr*r**i#s#si**##i*#irts#*#rtw*r*rwr*rtrww***s**sesrw«#i..w..wr.sssii*ir**s* <br /> SECTION Z- To be filled out b� PE removireontractor: <br /> �c �,j ac- A R-+�t0 % S o 1(� N'0"', c`� l� C <br /> manic Removal Contractor. <br /> Address: -2- O W l`i e-t S Sf• City:S n tA+rv�f o Zip: <br /> p'r4e voG <br /> Phone�#:( � ) V 1 `'l— 3 / 4 Date ernoved: <br /> **#*i*♦i«r«#*riw#•ii........i#irwiii*ir*r*rs#rirws*t#r#t*iiis#r*•#«w#w##.w..wr.iwwiiii#tss*#i*ii•*s*.#si**• <br /> SECTION 3-To be filled out by contractor"decontaminating testy P;(3e r v 47 L <br /> ?` © C 1 <br /> -weir Decontamination Contractor:�0 t p e- a G e-d ► n t��y S o�t�laaS o`S f� A L, <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 /> riiw•#r«rwiiisisiilii**iiiiii#iii♦i*#i*#ilii#t#r#i#rit#if#i#i#i#lit###ir•#r#ww##..#twt#ri.iiri#i##si#s*#•#* <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting4an4 andfor piping. <br /> Facility Name: / p a, <br /> Address: O lso X S �} City: t7e� V.Zip: D I �O 3 <br /> Phone -1r6-eN V d Q g S 9 9 d 16 <br /> Date T—vrk Received: <br /> Name: -Title: S,gnature: Date <br /> ♦•.•••r•••4r�••••••rr#•#rw••rr.writ#i•wr•#•.•w•r«#rw•#•.••.•*i*.«..«•#•Mw•M.••�-,rrrri*iriiiw#i•*ii•irt*#• <br /> r <br /> EH 23 046 (Revised 12)31/071 1 C1 <br />