Laserfiche WebLink
0 1 0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />L-NDERGROUND 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 />Mance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this farm is completed <br />acc ep <br />and returned- Ig <br />FACU,IT Y NAME: <br />S <br />FACILITY ADDRESS: <br />�Aj <br />� , <br />TANK ID #39 - <br />TANK SIZE' <br />-PREVIOUS TANK CONTENTS: i`>`- <br />SEC'T'ION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />City: Zlp' <br />I Date Tank Removed: <br />Phone #: () <br />e filled out by contractor "decontaminating tank": <br />SECTION 3 - To b <br />Tank Decontamination Contractor: <br />City: Zip: <br />Address: <br />Phone #: (� � � % <br />h si tare below that the tank has been decontaminated in an approved <br />through Authorized representative of contractor certifying g � <br />manner as required by Cal EPA. Date <br />f <br />itle:�if C __S bgnature: <br />Name: <br />5tora a or*disposal facility <br />�t*�r*rs* <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, g <br />accepting tank and/or piping. <br />Facility Name: CO "iD r- moi" , <br />City e Zip: <br />Address: fz_ <br />Phone #: 6019) <br />Date Tank Received: <br />r4 <br />Signature: <br />Date <br />Name: Tide: <br />EH 23 046 (Revised 3115102) <br />Page 14 <br />