Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EWIRONMLN7A.L HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> o..orr..or.rrr.•.r...a.rr•r.»r..r..r..rr..o..r....rrr..rv....•..........ro.............r............ <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Shea shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sbeet is to be returned to Public Health Services Environmental Health <br /> Division within 30 days 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 returned. <br /> FACILITY NAME: A — A Y-1- <br /> FACILITY ADDRESS: 3 13 3 N � d A r T R o as t 5 % o c K 7 o lj <br /> TA_NX ID r39 - 9 3 49 -3 TAN-iC SIZE: 500 qy I PREVIOUS TANK CONTENTS: wosr• O; I <br /> r....Y..Y.... ...........Yr..r..........v..rr...................YrrrYr.............0..................rvl. <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contracor. Ad V00 ( ed l')00 En VI r0hM-tN7c1 N C <br /> Address: K ODS M- W1,15601 Wok d City: 510 (K10&1 Zip: 9 5`10 5 <br /> Phone n: ) 6 7 ' OO 6 Date ?aak Removed: <br /> la.it.Y......r.Y....... <br /> .rrrrrom.........rr.rrYY... <br /> .i.rrrr......aY.Rr.r.r.Yir.... <br /> r rrl.......YrrrrrrYY....t>rl. <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: /14ya R ( +d (.,o r5Nyi N o n K9'H la 1 x N C . <br /> Address: 400y N. [ wilsdn rway city: 570(14)0Vl zip: 9h�D5_ <br /> 7 - 100 <br /> Authorized representative of contractor ce:Sfving through signatwe below that the tank Sas be--a decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Tit'.e: Signatw e: Date <br /> ..........................................r................................Y............................... <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or dispcsal facility <br /> accepting tank and/or pip t¢. <br /> FaciliryName: W1 ST CoaSITF �u;PM+J � <br /> Address: 5100 TaX101' CovrCity: rurlocK L"P: <br /> g538 ) <br /> Phone ,: ( <br /> 9 00 ) N N <br /> Date Tank Received: <br /> Tame: Title: Signatwe: Date <br /> .....................................................»................................................... <br /> EH 23 046 (Revised 9111/96) Page 10 <br />