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 1 — SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed <br /> and returned. �^ <br /> FACILITY NAME: t 1'I rrr hh w 1 Ni <br /> FACILITY ADDRESS: IZJV " WIIRVn NM. -TS`ffir,k h <br /> TANK 0#39—TANK SIZE: 10M _PREVIOUS TANK CONTENTS: A O I I KA <br /> ��:x*�+�xx�+�:�.:ter+�:+xx•exp+��.•:.x+:�.�xr�x��:.*��•�:�:+�::•�:,ems.:**��x�•.rte:�::•max:�xr*�+:x�...�+��x <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: nft)v / cssoU am <br /> Address: [)LAM <br /> q <br /> l+. _City:�ino 11� Zi P: ��16 1 <br /> Phone#: -IU W l J�Y 1YDate Tank Removed: <br /> •x+,t����.fx+x�xxzz+x�x:���xe+����x�se**��:s.��se�*:��x��r�����.����rx+«�:�,tx*������w:t��+��w,ex�x���,e:e�+x���� <br /> SECTION 3-To be filled out by contractor"decontaminating <br /> decontaminating tank": <br /> Tank Decontamination Contractor: urm �,MT(u5 <br /> Address: LAW L ntp00A Yd- <br /> City: dW Zip: oi <br /> btl <br /> Phone* L D �Jti3 �-1��() <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: Title: Signature: Date <br /> ��x�z*��x�x��:t:���xx�xi.�xtxwwk�x��:rz�����z��x�,txx.��:.�++:�x�w:r������z*�x��se����x►��x+���:�«�+����,t:�:r:ter <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tank and,/or pipings. <br /> Facility Name: JV1 the 1anLp.X sju.y p <br /> Address: 1j()I W` 1"•, 1 �Y)1bCAYC(Adsko City: k h Zip: <br /> Phone#: ( rJl " <br /> c) ) 11"b%' <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/30/12) 9 <br />