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REMOVAL_2013
EnvironmentalHealth
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PR0231073
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REMOVAL_2013
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Entry Properties
Last modified
4/1/2020 11:52:54 AM
Creation date
11/2/2018 6:48:35 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
REMOVAL
FileName_PostFix
2013
RECORD_ID
PR0231073
PE
2361
FACILITY_ID
FA0002064
FACILITY_NAME
7-ELEVEN INC. STORE #14117
STREET_NUMBER
2725
STREET_NAME
COUNTRY CLUB
STREET_TYPE
BLVD
City
STOCKTON
Zip
95204
CURRENT_STATUS
02
SITE_LOCATION
2725 COUNTRY CLUB BLVD
P_LOCATION
01
P_DISTRICT
003
QC Status
Approved
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SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\C\COUNTRY CLUB\2725\PR0231073\REMOVAL 2013.PDF
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EHD - Public
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u 22. 2b -13 9:33AM NNo. 3182 pP, 3 <br /> J . • . • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Teleplrane; (209)468-3420 Fax: (209)468-3933 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> • .v.»...».......e.... ......»..............«........w...,........<......r,.nn..x,....... <br /> .<....u.. <br /> SECTION 1 - SJC Environmental Health Department's Tank Tracking Sheol shall accompany each lank affixed with Ile site <br /> Idenfilicallon number. The Tank Tracking Sheol Is to be returned to the Environmental Health Department within 30 dens of <br /> acceptance of the lank byihe disposal or recycling fadfily. The permit holder Is responsible for ensuring that this form is completed <br /> and returned. yy <br /> FACILITY NAME: 7-/1ztl <br /> FACILITY ADDRESS: ? a�aNlNy ( / LI� Q.� baa/ vt L'�• �s���% -- <br /> TANK 1D U99-do6Vy°y3>^Sn7fANK SIZE:,./Or• 00 PREVIONS TANK CONTENT& 1!&f{511'i <br /> **tt***R***iY�A^YlrkYr*1:*%k**�tktiw+HNY3tt##R*L-k#**;t*****xRit,v*#t****Y****#it✓eibMN##'h****kk***kR*x;FRxt:V*Wt#* <br /> SECTION 2.To be tilled out by tank removal contractor: <br /> Tank RemovalContractoCJ r . wco. <br /> Address 170 ds?c, 'ti AaY, .SNr�& City:_„�rac-10 ZIP' . <br /> Is <br /> Phone 1/6 �beir-o Date Tank Removed' (i�!'l—� <br /> q.e4x^kkR*t*t*tt**tttb*t*tt FY%:F'd**k**it**94vrft**k*%i:Y*%***R***t31 kkN4ts:lk*******Axt*xYwttiWk*f:#k******R***x' <br /> SECTION 9-To be filled out by contractor-'deconlam/hl tank": . <br /> Tank Daconfaminallon Cohlractar: fr'd�rs•-f /�Yu/ac.s <br /> Address: /a� L� ALotia�y cRy- avr�rLta lip: �a Z�� <br /> Phone 4:( <br /> Autho0ad reprsesnfative of c0110111 or celfllying through signature below that the lank has been-deconlaminaled In an approved <br /> mannera requited by Cal _P& <br /> Name: ` TIIre �L/+'�l signature: Dale m 6 I <br /> #t#*AA k'k*RfaiwlhYNkf'i+tteAA-kit*tgtit.rXxR##i-kR#Rs*xt*kYurivis*se*Yki.^t***R*sR�r'w*N+c:eat***^k**#*krx xi*xx3*M*+*Krt <br /> 8EOTION 4.To be signed and di by an authoyll repreeenfallve of the treatment.storage,or disposal facility <br /> accepting tank andfor plift _ <br /> ty 1g /l / r, <br /> Naolll Name: s c os/ mob^ J <br /> Addreae:, / zip: lyf ,cZ <br /> Date TankKwelved Iw <br /> Nanta:,,,�7 14/'d...w TNIe' / Signature: '/ ala Z y� <br /> Et�29 046 QtovlaM 10/31u{2) 9 <br />
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