Laserfiche WebLink
SAN UIN COUNTY PUBLIC HEALTH SEI' LS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACIONG RECORD <br /> ►#r►rt#wtrt/i\r//ii►irr#4w44si\i►«iirtwW444trrrirt►r►4►#i##44\rtirrtrr►4►i4it4M#\4\ri►►44ii►rf\iirtiWWri##rt\i«\4\4 <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: 50 1 V\ K F 7 Z L Et�K N L A N E n t 1 <br /> TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br /> #\4rrwiW««rtrrrrt\iwrt/4r44r4r/\ppp►ppppr/rr►tis##\###►►iiWrtwrrtr«rt4w#irtrwwprariww/\irrswrps/rr«r#4rri <br /> SECTION 2- To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 5() \,�\ G 0 N S Z 0 \A <br /> , <br /> Address:Z,pSA(') \=RakAOM 6 ST City:5?OGlK-Tr)1\,� zip: )5?A0 <br /> Phone H: D Sa Date Tank Removed: r) <br /> si4r/s/r#►rwrrrrwwrr/www\rrprrr►\rrtrtrrw►wrrtwrr►#►prip#rpt\rrrt\riwwrtwprs\rwprtw4w44rrtrwirtrt►wrrrpw«4wr/ <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor- E L <br /> Address: 2 S � tea- ktC 7��_\l`�j City: zip: S,�go 1 <br /> Phone M: ( 51 O ) Z -5 5 - 1 3 P�3 - <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: Tide: Signature: Date <br /> prrrprtrrrr444\rps►#rr#W#pprrtrrw4rs+►iw#prp#►►rrrri►rrrwrrrwrtwrtr\►Ww\sirr►r►pp4sprr\p►w#►ws4i#srs <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: F_ L <br /> Address: KR " City:R�C w-w n\ zip: _L� X 01 <br /> Phone k: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ►\###rrtiWrrrrrtr\riwrpri\4rpsrssssrsssssspprwe4sps4rprwpr►wW4rts#swr4►rs4rrssrwwsprsrs:ssr«srs4ss«r <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />