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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />rrr+ssttss+e+rssrrsrsssrssrssrrssss+rtwtsr+trrttesrssrsss+ss+r+s+srssre+sss+,rrrsssssexe+rt+wrsssss+rr++ssrr <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 retumed to the Environmental Health Department within 30 da vs 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 <br />FACILITY <br />TANK ID #39 - dS.ZD R 1(o TANK SIZE:,39! QW/PREVIOUS TANK CONTENTS: g2.gr",6 %7G. <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: 1,���2 %!S ee �t �i� ur Y City: 4VQ.eP� Z. <br />Phone * (gW9 ) kl© 1 776 U Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. <br />Address:f Jti✓!G Q S a hd y -e—, 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. L <br />Name: � 1/.�,�s�ll „76nTitIe: a77%� Signature to � <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. —y-� <br />Facility Name: �a « ✓16t T 76 e— . / 1� <br />Address: ly S" ��7 City:�od�S6 Zip: J�'•J�•�'� <br />Phone#: <br />Date Tank Received: <br />see oe3g27T Cf�P[ Title: Signature: Date <br />yery l rG��'��% Ak 965;X--13 <br />EH 23 046 (Revised 7)26/2016) <br />