Laserfiche WebLink
%AW s <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVMONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> tilelite+#!#!!#4►►a14!##t►4i#►►rfffflatl4i#4####f!!a#fflf#!!lilt#ria#•#fftafa!##f4i#►l+f#►►►►►►tt##4+arra#w <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. 1 11 <br /> FACILITY NAME: J(Nti LCJEI 14_27 1�11�W�l�IIIZCZ <br /> FACILITY ADDRESSG: e�1j <br /> TANK ID #39 - I-ll ! -- --TANK SIZE: (("),OCy2 PREVIOUS TANK CONTENTS: <br /> rwl+rr+aw++iii►♦fill►+illi►#►1Hiall►►►►l4ltr#l4#4r44a#ir}#ai+t#Illliil+irlr4l+i!►!w#4##►fta►wa+►itia+rtwwa <br /> SECTION 2 - To be filled out by lank removal contractor: <br /> Tank Removal Contractor:s aa kA/AQa_ 2'M t-)` 7%km C/iJA&MUcx(CiA <br /> Address: (--) i1,CjX l (f City: A,1AVNtk1rin Zip: (�AS 2C `i <br /> Phone p: ( (7) ,=( G 2p.� Date Tank Removed: 0`1-_30-clq <br /> rrwralwr4fart!♦►r►ill►►#!Neill►ffla4aaaarlllila►►►►►rail#rlallairll!##laltailia4t#+++t+ilri►►*wrwi♦t♦+iiia <br /> SECTION 3 - To be rifled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: &-A1tn^''\\ h [IfU,Ct i(wl <br /> Address: )ZO 1�-�� )��nC� City: N k� n( titre. Zip: IV a(PC) <br /> Phone If: <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name:S' I# )a' Title: tYurtsr.�..� Signature: a Date 1 %-r <br /> wi**ala►lNtNt##r!##ff►►afN!####i4ff4####ifrr##!4##44f►!!alfarNl4##!!!fllff!#!#alar►Niel#lis*►#***!l!** <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: 1{-t C\L\C jV_ <br /> Address: �S�a �� Z I�D {fit L, City:�l� <br /> Phone A: (2 I(c, ) t4a ( - lQc\f7 <br /> Date Tank Received: 4 - 3 o " <br /> Name: [ 4 <br /> �. Al,� r"(5 Title: low, Sign Y, Date 4 <br /> w w a wa w*N#4##w N4♦ell**!►calla!altf#4r►i►r#lt!#Ml#/#►►►Nllf##4#rata+r##ll#+!l#hall►►l l#►►##!i*t!*+#R#rr <br /> Ell 23 046 (Revised 9/11/96) Page 10 <br />