Laserfiche WebLink
01/06/2003 16:56 2094671118 AGE STOCKTON PAGE 03 <br /> 01/06/2003 09:13 20946 33 FIFTH FLOOR PAGE b3 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALM DEI'ARTAMT <br /> IINDER[;ItOLT'D STORAGE TANK DISPOSITION TRACING RECORD <br /> #Yi#ssaaW#saarwaYWwrrtaakWtiiasxYs'+sssaWWYtiWWssY#WWraaaaWraasssYW##sslii#a#rawM#WYiaYYs#aksk#YawaasaaWWYiaa <br /> SECTION I_SOC Enviro»mental Health Depaxttnent's Tank Tracking Sheat'hall aecotttpany each Yank affixed with its site <br /> identiftation number. The Tam'tTracking Sheat is m be returned to the Envitotmxntal Health Depm=mt Mi 'u 30 days Of <br /> acceptance of the tank by the disposal or recycling facility. The petvttt holder is responsible£or enwring that thio form is completed <br /> andrettamcd. <br /> FACILITY NAN : LLI`w�ivLwrYL� rA tGL <br /> FACILITY 'DDREss= 2�( Srcr �+`i � + �s zLb <br /> TANK ID#39- S TANK SIZE-1.1vi—STD _PREVIOUS T.!M CONTENTS: U dW- mal <br /> Ni#YYsiraarFfsk#W s!x x#s##fisararWirrsaYlWiir}Y#rfiais##ria##aYfif#lxY4 Yf#liFwrtrasWiawpx#aWi#aaxYWYWas <br /> SECTION 2-To be Mad out by tank remavai co'ut�r�ac'to'r:: a7 <br /> Tank RemovalComrn / <br /> Contract= VALl.�t,�_��n.,,�lEij',1lLA(� <br /> Address: (4� (-G/ Luc AV)L City S/'OLtL7�Gr.L_ P �5�3 <br /> Fborta#:c,—.��� ��^�-z0/Y Date Tank Removed;_ <br /> xsa YW##artaF#rtsfa#Frfsss#Yi#ask#rtfWraawaw#4awasW#WaxrYwrfsr##iffYaWiii#fx#Fsss#lFWiWWFsrt+'rrsaaarYrskarYisaaa <br /> .SECTION 3-To be ftiled out by contractor"decontaminating task": <br /> Tank Decouta-in'tion Cmxtract0f: ,61I+ Q <br /> Address: City: zp1 <br /> Phone* <br /> Autbotized representative of contractor cettifying through signature below that the tank hU been decontattriaated in anV00ved <br /> rawer as required by Cal EFA. <br /> Nance: <br /> Title: Signature Data <br /> YwaasYWFWFas#kifiasilysWFaWWYNissaaWYiasxa:fiiissak##aaaawYaawa.MkaYrarWYWi#axYYOYiislYf#aasxYW#WY#ii'MYwsx## <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,atOm9e.Or disposal facility <br /> accepting tank and/or Piping, <br /> Facility Name: <br /> Address: <br /> City:_^zip: <br /> phone#: <br /> Date Tank Received: <br /> Name: <br /> Title: Sigrtatara: alt <br /> rrsrtFYWWartsssrfsssa#!r#a#laryrYlrrtfaa#YfWiaWWfrriisa#ifisaaar##f#ieN#TFaYWxiR#Y!Y##3fii+Ra#aasaa�w'Yiaae4Y### <br /> EH 23 046 (Revised 3/15/02) Page 10 <br />