Laserfiche WebLink
01/06/2003 16:56 2094673118 AGE STOCKTON PAGE 02 <br /> 01/06/2003 09:13 20946' 93 FIFTH FLOOR PAGE 03 <br /> SANJOAQUIlVCOUNTY <br /> ENVMONMT.NrAL HEALTIT nxPARTMENT <br /> 17NDERGROTIND STORAGE TANKDISPOSITION TRACKING RECORD <br /> YWkrssYYW#»*s+�W#Y##ssY»#WWYssz#stkxaa#z#WWssaax##Y%uzYW>usxxzrtsssaY##wTss<YW»Yw..#sMs:.W»s»WsaYrzYW#»sz <br /> SECTION I_SIC i nviro ffieatal ITtahh Department's Tank 7racking 9hce4 stall accompany each tank affixed with its site <br /> identification number, The Tank Tracking Sheet is to be returned to the Environmeatal Health Depmc=7 ttu 30 days of <br /> acceptance of the tank by the disposal or recycling faeility. The permit holder is responsible for emtning that this form is completed <br /> andxetomed. <br /> FACILITY NAME: L L 1417 G !J Y f `G <br /> PACIMTx ADDRESS: <br /> TANK ID#39- uDST 6 3 TANK SSZE= v!'5 J pREVIOTJS TANK CONTENTS: L+&WJL'CI-X�J <br /> ##r.+i##WY#WW%ax+k9W��w�W�haa+Y#rsaarWWa►r»Wwh W+li%Wi#rW>sis+k*#Y#s##WW#i#YhY##>#x#»kfs##W#%Wis#Y#W#a>sY#WW#>s <br /> SECTION 2-To be fMad out by tank removal contractor: <br /> Tsuk Removal Contractor. <br /> rQrl�� clay,q S'tiu�-tom/ _ zip263 <br /> Addres_ LL � <br /> aL <br /> phonekl �� 7GZ7 <br /> Datc T2, Removtd:v, 1- Z..F " Z• <br /> #Y»YWWW+aWWY#i#W#WW»%ssYW#i#fiW#a<r<wwW#WPasWYWr FwWwxWWs<wW##%xaxWY»>###WW#>Y####+Ffi#YW#W#axaY#WW>s�#»Y4f>aW <br /> SECTION 3,To be filled out by contractor"decontaminating tante": <br /> Tank Decontamination Contractor. ,„,� <br /> Address: City-- zip, <br /> Phone#:(,) <br /> Authorized representative of contractor certifying thiaogh signature below that the tank has been decontaminated in an approved <br /> ma>mer as te4nuad by Cal EPA. <br /> Name: <br /> Title: Signature: Date <br /> W#fi#srWrrWfixx#tr>sa•iY##as#zW»%fissxrrts>s###»Waass##»tsa.tW»#>ssWWWaxs.WWWwsa#»WWx>%#WW#»s#YW»%ss#WW#YYSY#N <br /> SECTION 4-Yo be signed and dated by an authorized representative of the treatment,storage,or disposal tuility <br /> accepting teals and/or piping. <br /> Fwmty Name: <br /> Address: <br /> City:_, —zip: <br /> phone#:(^� <br /> Date Tank Received: <br /> Name• <br /> Title: Si%natum: Date <br /> ...w#www>rrssrrtssssY»r#axx»%>sYr<>fi#zrs•••sYWWWYr•rsrwr•Ww#WW%>rzsrrsfi#rrassYY%%sac»YssYW#s»#sazYY*ssw+WWs <br /> E1123 046 (Revlsed3115/02) Page 10 <br />