Laserfiche WebLink
FEB 28 2002 3:36PM <br />,11/2007 09:59 <br />'12/20/2606 12:49 <br />LASERJET 3200 <br />64P' 18 <br />EHD • <br />ENVIRONMENTAL HEALTH <br />P.3 <br />PAGE 11 <br />PAGE 1B/I1 <br />ENVIROENTAL HEALTH DEPARTMENT <br />SAN JOAQ11N COUNTY <br />tiphQue: (209) 463-34 20 Fax; (209) 468-3433 <br />UNDERGROUND STORAGE TANK IMPOSITION TRACKING RECORD <br />•.. I .... ..b.... r• ....... .rYY...\i.......11L.f 1.I .....\..III....... <br />SECTION 1 - SIC Environtrsrnul Health Pcpenmcnl's Tank racking Shcet shell accompany each uAk affixed with its we <br />!deni6eation number. The Tank Tricking Shier is to be retum d to the Environmental health DepaRtoent within 30 days of <br />::ceptanee of the rank by the di sp aal or recycling facility. T it permit h0der is rasponsible for ensud5l; that dtis form is <br />nrTicied and renamed. - <br />FnCIWTYNnME, <br />F.ACILITYAD.DRESS: Z�yC ri 1 V -t. - <br />TANK ID <br />♦...INNpL79aIo. S (S 06_PREVIOUS TANK CONTENTS: oCJ tiQ$L — <br />a.1. <br />.1 WAV e/0e .ILYu. of. .Y.elgeeea♦ .Hl.......b..A.........Y.........q.............• <br />SECTION 2 - To be filled out by lank removal contractor: <br />Tsnk Removal Cordawor: ,,,a&7 <br />Address• CltyJ_[0�7,i —[SZ- W <br />Phone a;(gbCO Date Tank Removed! /"?67-O'% <br />...............................Y»....o...r... a1..... .11.1\1}..10.....0............. 1..................... <br />SECTION) . To be filled out by COPtr■ctor "dttontaminuinR link <br />Tank Decontamination Conmaclar: ^rOcAL'Cn4 V l Gr,- <br />nddrrsa: V 14, L�,� �'74'�I.4 Ciry<!;acprT 71p: qs�'s <br />Phone R:CIZ-o <br />Authorized representative of conVact r cartifyiog tb7otsgh signatutsZolk 7cm dccoaesm(nsteA in an approved <br />Author se repro a to Cal EPA.Name. ( T11k Date x-- _ <br />0000..... w........ ♦. I o.1.... ..41..1.. \. Y...1.0b .. . HH I \ N. N u. \0000 H M ..1 N 111.11 H ♦ M \ N.. q. u 1 <br />SEC710N 4 . To be sip0d and dote by an sulborized represents tvc of the rrcoancat, storage, or disposal facility <br />,accep ' g took and/or ptpi . <br />FW 1Q:1 r <br />Addres Ci ; &P: `L52-Q_�_ <br />phone 4. �8. 9 <br />"'knit ~rr ll,i1- T t1e: Sigaatatic: <br />' _ <br />.....\II.I......I..t\\Ii1I\\.\\...........\1...\/..1.1 .e\IR\. \\II IIa\er.1111i111111.111.111\\\\\■11.1.\ <br />EH 23 046 (Revised 11/21106) ),p <br />