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0 <br />F 1 <br />L__j <br />j 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 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 CON IEN 1s: <br />Phone #:�)__t_1-- 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. # t . - . . a <br />Facility Name:- <br />--- _ City. Zip: <br />Phone #: <br />Date Tank Received <br />Name: Title: Signature: Date <br />EH 23 046 (Revised 07/22/10) 9 <br />