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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY Telephone: (209)468-3420 Fax: (209)468-3433 UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD .......................................................................................................... SECTION 1 - SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of acceptance of the tank by the disposal or recycling facility, The permit holder Is responsible for ensuring that this form is completed and returned. FACILITY NAME: 7�`-�✓za 0_1A .¢r&Srs'O FACILITY ADDRESS:_ /397$- �• Nu'y g15r LaCA Cioi2 J,CA • QCa 37 TANK I0#39- 3T_AldK5 TANKSIZE: 100000 L-A[ PREVIOUS TANK CONTENTS: (;,ASo C/A)E_ SECTION 2-To be filled out by tank removal contractor. Tank Removal Contractor: 48t'C- mA/Al2�FM�E Address: 3 `� r�cy�oNac Pku)y City: 5AXIIA A45A Zip: CI5-SCO3 Phone#: 7, �7 ) .S`I�S- —SS22 Dale Tank Removed: SECTION 3-To be filled out by contractor"decontaminating tank": Tank Decontamination Contractor: 4 t�A M-v> ,ga/z\//C� IWC Address: T,96 E . FkpA/OrZA BCV/, City: Zip: 90 Y5/ Phone#: 3( /0 ) S23 -- 5/y30 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Name: Title: Signature: Date SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: // /P�/�/6LrG S�.=Kvrc�g, - VAsc.O POAb LAA/o fiiCC.. Address: 70D� Al, %(A,,-co RoAD City: &'/ Wcyeor C^ - �'ys�'✓ Phone#:(O0U_) L (12-) coamc-T— -toe- Date Tank Received: Name: Title: Signature:_ Date `PNk #t EH 23 046 (Revised&/1/I 1) 9