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Ll <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />12 <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 return ' <br />FACILITY <br />FACILITY <br />TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTEN r5: <br />Phone #; ) �� i_1__L1— Date Tank Removed: <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 />SECTION 4 -To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. i , _ , \ e <br />Facility Name: - <br />Address: <br />Phone #: <br />City: <br />Zip; <br />Date Tank Received: <br />Name: Title: Signature: Date <br />EH 23 046 (Revised 07/22/10) 9 <br />