Laserfiche WebLink
Dec- 12-96 09: 26A Wayne Perry Inc . 714 523-7880 P -02 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACIUNG RECORD <br /> www.w .......o..... .... ...r.r.rr.ss......r.....r..... ....................................... <br /> SECTION 1 - public Health Services Environmental Health Division Tank Traclang Sheet shall accompany each tank affixed <br /> with its site identification number- The Tank Tracking Sheet is to be tenoned to Public Health Services Environmental Health <br /> Division within 30 da.s of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and resumed. <br /> FACILITY NAME: <br /> FACILITY ADDRESS:_Lyit> N <br /> TANK M #39 - TANK SME: lc),DDQ REVIOUS TANK CONTENTS: <br /> .................................sw.wwr...............w.....rw................ov................. <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Conrraeror. <br /> Address: SFUI Ciry: nw.Wa'YPLL Zip: °Iouz.I <br /> Phone X: ( "1 ty -) B2Y 0352_ Date Tank Removed: <br /> ...........ws.........woo.e.rrrr....r.w.o...rr.....w.o................r.r....uso.............. <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decoutaminariou Courractor. env QV,,N& <br /> Address: t-(QL &A City:(-yksil,&A Zip: %?Ll4 <br /> Phone A: ( 31 b ) L —yN30 <br /> Authorized representative of contactor certifying through sig=ure below than the rank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Tide: Signantre: Daze <br /> •.www.........w.w..wr...ww......w.w.rrrpy...w...w....rr..........ww......................... <br /> SECTION a - To be signed and dated by an authorized representative of the¢ramicat.storage. or disposal facility <br /> acc <br /> e <br /> p <br /> ting tank and/or piping. <br /> Faciliry Name: SA <br /> Address: ?2.00 F aA, FLawA4a SA A City: Zip: c)28I6> <br /> Phone #: <br /> Date Tank Received: <br /> Name: Title. Sigaarare: Due <br /> ......................................................................................................... <br /> EH 23 046 (Revised 7110196) Page 10 <br />