Laserfiche WebLink
M <br />M <br />NV ON El �ffA Ld11 A L74-7 JSl/ yll d L1Cl' T V E_TN7 <br />SAN JOAQURN COUNTY <br />Telephone: (209) 4619-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RE' CDRID <br />SECTION I - SIC 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 returned to the Environmental Health Department within 30 days of <br />acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is <br />completed and returned. <br />FACILITY NAME: �' 1 )�t 043,-% <br />,se, _ L_ i_ <br />FACILITY ADDRESS: �i�Q`.)L' , Jt(4'1� �� <br />TANK ID #39 - TANI' SIZE: l �.i�' , Ca Y � PREVIOUS TANICCONTENTS: `-in')6'.j?��i; <br />########}}##k########}##}###:F.#:k{::k:k###i:#########•###{e:k#{:{::k#:I:###:k#:k####}p#:k:k:k######k:k##:k###:i:#####:k##}###:F##### <br />SECTION 2 - To be filled out by tank removal contractor: <br />- <br />TankRemovalCoatractor: 0+t4;'LT <br />� +0.0Zip: <br />Address: �wrCity: CtLJ�`tl <br />' Date TaRemoved: #: ( ZLtd C 77 .Q01 <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: �V .D <br />Phone #:( C' I) Z ' I'S <br />:C1 c,�-r� �[11141fYlt!'tfn�-ti.ti.. �"Yb-ViC�i.S, (1C: <br />--City: %I'CLC Zip: <br />Authorized representative of contractor certifying through signature below that the, t� <br />manner as required by Cal EPA. 11 ' <br />Namcj- C,�N)) UV1 vl Title:?f Si0-,A Signature:'_ <br />SECTION 4 - To be signed and dated by an authorized representative of the <br />accepting tank and/or piping. <br />has been decontaminated in anapproved <br />it ''V' <br />storage, or disposal facility <br />Address: 1�� �L�1Y1' L.'1C:� City: ll.� �( i Zip: <br />{ <br />Phone #: :( C O 1F --- <br />Date Tank Received: <br />WIMM <br />Title:cL� Signature: <br />EH23046 (Revised12/3!/07) 10 <br />