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 />SECTION t – 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 <br />TANK ID #39 - i) TANK SIZE: o2 06P/O PREVIOUS TANK CONTENTS: o/-45�S.eL <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: ✓/ /YI /h!, <br />Address: 1?O t3L) X <br />city:_ 41—al–)l zip: c/S �- <br />Phone #: ( Z o q )_ 36* 6 / 7 S Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. <br />Phone #: (2 ceOl i 36 <br />city: 0/� zip:_ 9 S L �4/ <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 />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />01 accepting tank and/or piping. <br />TnlKS ru <br />Facility Name:_ 0(d�yrl, j�4� i/� 2 (]�l/1�� %,/l�/�l L� ✓'7`'�/% -T�-L-L_LL/ <br />Address: <,5, Zip: <br />Phone #: ( 2 0) <br />Date Tank <br />Name: Title: Signature: Date <br />j�TcEL r'��i,�� •rp <br />f1 f)1)l2FSS <br />_ l'i-IO.J r st <br />ride ^'6C'ASS <br />EH 23 046 <br />SC-1Y1V/Tzc/Z STE L PROO✓C7'5 <br />/ 2d00- r'OGSB/y/ r2e74v iZ9n9CNC/ Com.?�cd/9 y� 7yL <br />('716) 97iiS•-`fLwlo Srf_rJli..sC <br />To , r6Rag2/,30 /mode-, <br />i41)7MtY s ?992 S, 40S 7 -1-J Roolr.) <br />/r <br />C•9 • q 5 j -3G" <br />