Laserfiche WebLink
0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />f,Nf 1f 1NN1N11NN111NNf N1.......... 11f 11ttN1f f NNNMf N1f N11NNf 11NNN11NN1f 1NN1N <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. c �e <br />FACILITY NAME:_534A jCAM1,14 <br />% `- /Oitj�Z A1pS/ J'- d/ ST JC > <br />FACILITY ADDRESS: i E4 l 7 <br />G/^fy)S&V <br />TANK ID #39- _Q_L 5S7JS TANK SIZE: PREVIOUS TANK CONTENTS: It3-,o� L <br />SECTION 2 - To be filled out ✓ by tr <br />hank removal contractor. <br />Tank Removal Contractor. _ iy 72ole r2,E ole /,Vc, <br />Address: Po 3o x 3 5 / -7City: Z_ ew l Zip: 2 <br />Phone*.( Z0'1) 315,4-6p/7S Date Tank Removed; <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. //%/ & 1e r7,e 69/,1 /,1 G , <br />Address: e d 43ox3 z5; City: Zoo/ Zip: CJS -L <br />Phone# Zc' _3696/7$ <br />Authorized representative of contractor certifying through signature below that the tank he n de ntam' ated in an approved <br />manner as required by Cal EPA. <br />A � 11 � <br />Name: 72_4 2&0 ?t�f TitIe:[ r2,J///�!T 2 Signature; Date. �G l <br />SECTION 4 - To be signed and dated by an authorized representative of the treatme4storage, or disposal facility <br />%, .� accepting tank and/or piping. <br />V //i JY,s TJ '/ff�A _ <br />Facility Name: W /, �C• L <br />Address: �9q`�6S S? -'V lcu4� City:>WW/tiT�1% Zip:g��_?3_6_ <br />Phone <br />Date T <br />Name: <br />ADRC2 5 <br />_ e4owesr <br />ri36�'6CFSS <br />EH 23 046 <br />Sc-)YI)lrzc/ZSTi_tL P1?0L)✓c TS <br />/Z-000 /'OGSO/y! [ZOAI) i�V9�C/iD Co.2Jc'r1i¢ <br />1 C?16) ygs ,- ��/ 0 <br />ro <br />140,2465 9 y 9 9 S• �i N5 T, J i2�9s1A ✓r/i1�JTFC9 r•q <br />,4,6 -d (Z-0 <br />-',- 7y -L <br />9 -, 3_jr <br />