Laserfiche WebLink
ENTAL 11 ALTu DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 - 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 />m <br />completed and retued_ <br />, e-Blal') R�9C CFS/f/7� �/1%l/�s�/%%F.✓%`f <br />- FACILITY ADDRESS: .,Z �� S• G L /�O /� <br />TANK lD#39 - OSl 9 $ ej ,C TANK SIZE:3,QQ O PREVIOUS TANK CONTENTS:_ 4/nik <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: JY,V4I � x- Q/C 14c <br />Address: I� O 23 ox- . Jr % ^1.S� T <br />L- City: G¢%/� I zip: <br />Phone #: () j 7 S�� % Date Tank Removed:- <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor:. .J/7/yf �jy-Q/ZI�f 6/e -t - <br />Address:_ �(� 60�C. / City: Z49L2 / Zip: ��Gt 2!fZ - <br />Phone #: <br />Authorized representative of contractor certifying through signature below that the t been decontaminated in an approved <br />manner as required by Cal EPA. /� <br />Name,,M71-4 //f�OR%£ Title:C&)�/t/}G�lrj/L Signature: _ _ _Date /V <br />SECTION 4 - To be signed and dated by an authorized representative ofthftreatrknt, storage, of disposal facility <br />__.. <br />accepting tank <br />�and/or piping- <br />FacilityName: S e�f,J % TZ L� ,S /rC £l J Z&26/GT S <br />city: Coe Joy.} Zip: <br />-- Phone <br />Name:0314 ( ..,1t22A-1 Title:t,t�N 94"Qlt`_IL Signature: Date <br />##########################################################o######################################## <br />EH 23 046 (Revised 12/31/07) 10 <br />Z <br />