Laserfiche WebLink
4-06-1998 8:59AM FRSTAIT SACRAMENTO 916 635 2606 p- Ili <br /> • <br /> SAN JOAQUI'N COUNTY p MUr-MALTH SERVICES <br /> ENVMONMENTAL HEALTH DMSION <br /> UNDERGROUND STORAGE TANK DISPOSTI'ION TRAC WNG RECORD <br /> r+*r4+w4+ar4Wrwr4•+r.r+r.4r*n+rw'b44aw4r+row+w++r+wwWW444r4w44rwrwrw4rrwr�4rw4wr+w+rrrwwrr4+w�ww4w++rer+n+W+w <br /> 5ECTiON 1 - Public Health SCBvirts Eevirrnameatal Health DiviS100 Tattk Tag Shtir shalt a=MPffiy ela �a�� <br /> with its site identi blic Health <br /> Sc r. The Tank Tracking Shat is tO bo rcuuned ro Public Health Soviets EnVt"OnMeMal Health <br /> Division within 30 dW of acceptamee <br /> Of chc tank-i the disposal or recyCiin3 F�ty- The In�u ]older is respomsible for <br /> ensuring that this form is completed and remtned- <br /> FACILn NAME: L <br /> FACHZN ADDRESS: f2Ac rl �""� <br /> TANK ID #39 -_ TANK PREVIOUS TANK CONTENTS: <br /> 4Nrssrrrwrrtr44«wrrw4rrr�.r+4444»wrrWsww►r*.a'rrrf444r4wwrrrtWwwrrtw•rr«n««sr+«rrrrirtra4sww414w/+`+'rw4M'W'4wwwrr <br /> SECTION 2 - To be filled out by tack "moval contractor' <br /> Tank Removal Cauu2=Or-- �'---- <br /> City:��r_ zRp: —_ <br /> Address: <br /> Phone : (!�)� Date Tank R=oved <br /> 4Wr4Wr444w44w44444r4oFMwr4444arr44Arwrr++`r4+w44rw4r^P4r•444•wrwt«r�l.wrwrrwtr+tr'wrYwr44wr«rw«rw W 4.4r44w <br /> SECTION 3 -To be filled out by cuatractOr "decoomminating tank": <br /> Tank DeenmtaminadOm COutf3mr <br /> ctty:��_.zip: <br /> Addznu: <br /> Phone#: <br /> Authorized uepresentmvc of connecter=rdfyiug thmagh sigttatttte below that be tank has beta dectmr+ ; =d in an approved <br /> =armor as required by Cal EPA- <br /> Name <br /> wrMr•r 4441rrtnn4w44rrY4«+*'4rrrw4f�sw4rrYr4444tr444rr+wd4#4•dwwrfrrrw444r44rrt+4w4rr/4444wrr4b4+rtwr►r4rw <br /> SECTION 4-To be signed and dazed by ao <br /> auhoriced reprwentatlwe Of the uvacv=,stordge, or disposal facility <br /> accepting tank attdlor piping. <br /> Facility Name: <br /> Caty <br /> Address: Zip: <br /> Phase A: <br /> Date Turk R=tved:��_� --- <br /> Name Title: signature' Date <br /> r44rr4wrer444rr44r4wwwr++fw*+ <br /> wwwrn4rrrrrww4+o-r4rw.w+wwrww*»«dr•r4rwwWr«rrrr4444pww44rtrtw4rw4+�*4www:rtr <br /> ER 23 046 (Revised 9111196) Page 10 <br />