Laserfiche WebLink
SAN JO/ TIN COUNTY PUBLIC HEALTH SERVIC <br /> E,VIRONMENfAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACIONG RECORD <br /> MMM«WWrtrt«iMMM,FMMMMMWW«MMWMMWWWWMrtrtMMMWrtrtW«M,k«MM1+F«rtW««MM«MW«RiMMW««rtM«MMrtMM«MM,k«MWM«rtW«iM«W«MW«4«M«rtMW«tWW«« <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 /> vnghin vs 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 /> FACnM NAME: ip/I CIEI Z W/ <br /> FACILITY ADDRESS: � 2� �. 4 21Z (�/OO LO. S/–�l'CI <br /> II/L�21 (2( <br /> TANK ID S39 -/, 00TANK SIZE: O® PREVIOUS TANK CONTENTS: jC <br /> 1 MMWMWrtrt«rtiRMWMMMMMM««rtMMMMrt,krtWW««M,trt+k«««MWW«W««M«MMMrt#iWrt,krtrtrtWWMMMrtrtrtWMrtrtWMrtrtrtM,krt«irtW,kWW«M1MWrt,kMW MrtiW« MWWW <br /> f <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor. <br /> Address: �3 S� i✓, !3 G/Ci'% /Z%. City: C p0/, (/ zip: <br /> Phone#: ( ;Lo 3 e7 �e Date Tank Removed: oZ <br /> I �M,iMMXVWWrtii»rtMM,kMWMWWM«M«MMWWWWWMbMMWWMM«M«M«WW«WM,FqW«rtMWtl«rtMM#M«M«rtirt«i«MMWM«rtrtWMWMMrtrt«MMMM«M«WWW4WMMMR <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address:�7 — 7 City: Zee/ Zip: '2 ,z LO' <br /> Phone N: ( Z(s C7) S(f—/ <br /> Authorized representative of contractor certifying through signature below that the been ted m an alproved <br /> ntamer as required by Cal EPA. <br /> Name: /�/t' Q �£ Title: ��fS�I/F��Signature: �i Dau / <br /> M4MMMMM«sWW4rtrtrt«rt«wM«rtrtrtMMMWWMMWMi«MWMrtrt«rtrtrtWWMMr«MM.trtMMMMMWWMWMM rt«« rtrtrtMW« rt«i MMWMrt,rrtWMM«WMWMM«wrtM« <br /> SECTION 4-To be signed and dated by an authorized representative of the trea "e, or Lsposal facility <br /> accepting tank and/or piping. _I <br /> Facility Name: L/(/ 7�� � �_ l <br /> Address: (Q SG/�s�T// I IL�Q CnU/ ��b/y:& �up: r <br /> Phone#: (�Oa).1 C�41 3 <br /> Date Tank Received: <br /> Name: Title: Sigmante: Dare <br /> MMMMtM4WMaitrtrtrtrtrtrtMrtiM1rtrtrtMMiMMM+F«MrtrtrtMMMrt+krtMWMMMMMrtWMi«aFMMWrtrtMRbRMrt«MMMrtrt,k«RMMMf,rtrtrtrt/+kMMMMMMMrtMrtrtM«A�irtR <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />