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ENVIRONMENTAL A T <br /> SAN JOA UIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> i <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 NAMwrliE <br /> FACILITY ADDRESS: 2,,�Zj W% IMSSWINA"W STt 5ioor_yuy, CA c?52o& <br /> TANK ID#39- -PiMX <br /> ****** ATANK SIZE: — 000 &*L PREVIOUS TANK CONTENTS: UNC h <br /> q -0s* <br /> SECTION 2-To be filled out by tank removal contractor: ,��^^ <br /> Tank Removal Contractor: V?R0JMr ?M ! ! -rat. <br /> Address: 3&f OD jK_ S City: DA S rte Zip. 13706 <br /> Phone#: Date Tank Removed: <br /> i <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: <br /> A <br /> Address: 3"400 City: O GL3 Ff q D Zip: t � <br /> Phone#:( 661 ) <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. j <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. <br /> Facility Name: <br /> Address: City: Zip: t <br /> Phone#:�) <br /> Date Tank Received: <br /> j <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 8/1/11) 9 <br />