Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION#TRACKING RECORD <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 3 to be returned to the Environmental Health Department within 3o days of <br /> acceptance of the rank by the disposal or recycling facility. <br /> completed and returned. The permit holder is responsible for insuring that this form is <br /> 11 '' /` ,r� <br /> FACILITYNANjE: �oc., l C_ko r` tL S (-<j- <br /> FACILITY <br /> FACILITYADDRESS:�( S �G �r k� s. C, <br /> TANK ID 439- <br /> f.,'--JK SIZE: PREVIOUS TANK CONTENTS:-- <br /> SECTION <br /> ONTENTS: _SECTION 2 -To be tilled our by tank removal contractor: <br /> Tank Removal Contractor; ✓ e � �A C'1 c -5e- e i./,'c1 f i <br /> Address: Pd . & 1(o75 <br /> City:_- Zip: <br /> Phone#: (��a, %2E,�- - '"[E%Date Tank Removed: <br /> SECTION3-To be filled out by contractor"decontaminating tank": <br /> 'rank Decontamination Contractor. _ � (' j- r3i Lf= '�G�� -Z?iC <br /> Address: Y,B & /& J„ <br /> City: ZZ., 1/ <br /> &4JZip: "I„5 77 b <br /> Phone#:(�3D ) �{'�' Z _ �.�i..F ( <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> :Wanner as required by Cal EPA. <br /> name. Title: <br /> Signature: Date_ _ <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepti <br /> ng <br /> tank and/or piping. <br /> :7acility Name:_7 <br /> ,ddress: 9"'17. P ag l u z{ <br /> f <br /> G City: )'( 'G�tt'h0�"= Zip: <br /> "hone #: <br /> ate Tank Received: <br /> ame:e�Glstot <br /> ACLO 5l KG rI Siamature: mor on / Date_ <br /> -i!23046 (Revised I l!2i!O6) 0 <br /> 6'd 60MCZMSI puowyoia - 1 0 3 BLVLl LO OZ Jeal <br />