Laserfiche WebLink
SAN#AQUfN COUNTY PUBLIC HEALTH SEAES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - 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- .4 1cf r:� <br /> ��. cR "� <br /> el <br /> TANK ID #39 - 1 TANK SIZE PREVIOUS TANK CONTENTS: , <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: " &4�L (f `N <br /> Address: I ck ---� CityT e-JCTZ j Zip: qS o-as— <br /> Phone #: (2 t ) 3 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor:S � ���� (`it - c `�-• '; r� <br /> Address: <br /> Mme. l`1 i r11� L `7' C City:'Jc .t- �U Zip:�� �•' <br /> Phone #: <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 /> 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:CA[-- (::C7'Ps`—t -T <br /> — <br /> Address. City: Zip: �� <br /> Phone #: ( 7&i ) •6? •-q�'/ a <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />