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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY Telephone: (209)468-3420 Fax: (209)468-3433 UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD ..........................................................................»......I...................,.,.. 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: Tom`-�'z0 C/SA ��n 81So FACILITY ADDRESS: /3975' &--• /-/WyBg ,, La�/i.cPorLiJ, CP • cTC23•� TANK ID#39- 3T_M*5 TANKSIZE: /Oro0o CAC PREVIOUS TANK CONTENTS: C?a50(111/r= *iWr#WaWWra###W#*rW#rr#rw#WWrW#r**WWw##*#*wWwr+a++a*WWir+*iW#r#wrawa*W###r##wiWWWw##Wx+rw#+awaawrrrw#*ir SECTION 2-To be filled out by tank removal contractor: Tank Removal Contractor: ,e1,B4.6" 1"A/A/j`2-7A1C;e_ /,-/C- Address: teaAddress: 31)L 41 Pcc�ia�NA� I*W y City 5Mr7* Q55A zip: el5-,fo3 Phone#:( ©� ) S /S -'SS.Z 2... Date Tank Removed: SECTION 3-To be filled out by contractor"decontaminating tank": Tank Decontamination Contractor: A Z3A ill AE/2VIO�< , /WC Address: T/ 6 G . Aco_14W-k A011) City: �`J��i)�/J,� Zip: 90.4; Phone#:13 10 ) Sz3 "- Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cel EPA. Name: Title: Signature: Date WWira#w##WrWa#wwiWWW*WWWw#Ww WrW#rW####+*aai#WWr#rrr#r#r#i*a#W**WWrW#rr++r#a*WW+rrrrrwa*+###ririirw##w+WW 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/ /�� •'/�L- `-' KWC�S• ._ \/A�co ROA11 C,nn/o Address: 57,00 Al. VA-,co /1oAQ Cit L„/e:�'iHl✓ge�, A - ez./,5'r/ Phone r5d0 ) ZoY_ Date Tank Received: Name: Tills: Signature: Date EH23046 (RevisedlUl/II) 9