Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONNIENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> •>+•••rrrrr••rrwrr>r••wrw>rwww»«•>rarerr+rwwr♦r••rrr•rrrrr»rra>rrarrrwr>rrw>q>rgrwrrrr rrrwr>awrrrrrrr• <br /> SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: CHEVRON STATION <br /> FACILITY ADDRESS: 139 S. CENTER STREET <br /> 0 D3-(D(e <br /> TANK ID#39- zarrgcr TANK SIZE: 101< PREVIOUS TANK CONTENTS: NIB6RJlE1€ <br /> •orwrr>w>rrrrr•r>##♦•wr♦rrrrrrrrr•+rraarr»>rrw•r•r>rrr>•rarr•rwwarw+rrrr>r•saaarr>r>rrrrarrrarrwrrrrawra♦ <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor. MUSCO EXCAVATORS, INC. <br /> Address: 2526 GREENVALE COURT City: SANTA ROSA Zip: 95401 <br /> Phone p: ( 707 ) 579-0250 Date Tank Removed: <br /> •r>urrura>.>.uurrrw••w>••w«rrrw»r>rrwrrrrr uwrrr..>rr>•♦r>.r>rrr»•rrrrp+rrrrrrwrrrrrwwrrq+awr r>w r• <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor E.C.I. <br /> Address: 255 PARR BLVD. City: RICHMOND Zip: 94801 <br /> Phone N'. ( 510 ) 235-1393 <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 /> .......................... <br /> aterr....r.rrr«rrrrr.+..r+#rr r«r...r... >r r r r r.r>w>w w....... <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank andlor piping. <br /> i <br /> Facility Name: E.C.I. <br /> i <br /> Address: 255 PARR BLVD. City: RICHMOND Zip: 94801 <br /> Phone p: ( 510 ) 235-1393 <br /> I <br /> iDate Tank Received: <br /> Name: Title: Signature: Date <br /> rrarrawrarrrrrr+rsrwratarratrrrrrsa#rrarsrrrrssrrrrrrssaa>aaa#wrrrrrrtrraara#arrrrsrsrrtrasrrwwwarrrsrrrra <br /> EH 23 046 (Revised 08/13/99) Page 10 <br /> i <br />