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 />...............................».....................................................,................... <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 <br />FACILITY ADDRESS: 1 0i¢ % * e/hfr)�dy <br />TANK ID #39 / e/5$/5 TANK SIZE:o•ZOOT OO _PREVIOUS TANK CONTENTS:�I�S� L <br />»x»+»»»»xx+xx+xxxx»xxxx+xx»»xxx+»x*»»»x+xx»»xxx»»»+xxx+»xxx»»+xx»+x»+»xxx»»x»»+xxxxxx+xx»»x++++x++++++x» <br />SECTION 2 - To be filled out by thank removal contractor <br />Tank Removal Contractor. •-J%/!7 ///p/ I2t Ole /,VC <br />Address: Po 3y ( 3 5 7 city: Z - y /) / Zip: S <br />Phone #: ( 2 � �7) ,3(r � 6,1 7 5 Date Tank Removed: J `- Y- %L <br />»»xx+xxxxxx»++xxxxx»»xx+xxx»+x+»»x+x++xxrxxx»xxxxxx++xx»»xxxxxx+xx»+++x+»xx+xxxx+x+xxx+++++x+x+xx++++++» <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. <br />Address: Y d L50X 3 5 / City: ZOO/ Zip: 2 5--Z <br />�L <br />Phone#: 2e 36 6/75 <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:M,riQ7� �/�O/?I2IZ Title:( �%JL"e-*70%� Signature: ti/ Date o�-/ <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility� <br />//fAniKS Tv accepting tank and/or piping. <br />FacilityName:_2Gf)41L0 7/l)G�•_j <br />Llii/(7L`/ <br />Z <br />ip: �IS3j f <br />S �h SII/ Tzc'/Z S T2 j� L PROI)VC 5 <br />1101)IZFS5 / ZLdv0' r0(_Sv/n r'Z04L) i2An9010 Cr9,2,7crV,4 c) -:;r 7,/-L <br />u't Z6�955 Tp <br />j // /.✓ d /4IM11 s s 9 9 9 9 S. /Ii NS Ti1J j2�� Ar) ✓nilnl %6 C�9 C•9 • 9 33G <br />I�No.4E -4 (Z09, <br />EH 23 046 (Revised 10/30/12) <br />