|
ENwR ONMENTAL HEALTH DEPARTMENT,
<br /> .SAN JOAQUTN COUNTY
<br /> Telephoner(209)46S3420. Fat: (209)468-3433
<br /> UNDERGROUND.STORAGE TANK DISPOSITION TRACKING RECORD
<br /> .,,,,......,..,,.....;..,,...n,,,.... ,.,, ...,.,,.,.,,,;.ti,.,,..,..,,,..,.,.....,f.,.......;.,.,,,...
<br /> SECTION-1 — SJC Envlrohmental Health Department`s Tank Tracldng Sheet shall accompany each tank affixed with Its site
<br /> Identification number. The Tank Tracking Sheet Is to be retumed to the EmAronmental Health Department within. 30 days of
<br /> acceptance ofthe tank bythe disposal or recycling facility. The permit holder Is responsible for ensuring that thlsfonn ;s completed
<br /> and retumed.
<br /> FAC fL MY NAME: Ptm n
<br /> FACU YADDRESS: SSD NA), N)gl Vl Cb ad I 6911
<br /> 01510,S60
<br /> TANK Ii- TANK S IZE: 2 2�� PREVIOUS TANK CONTENTS: O'eSc.1 J 61 1 t n 2
<br /> ***A AA
<br /> SECTION 2-To l filed out by tank removal contractor: T
<br /> Tank Removal Contractor: 1i�7eno�a- 0.•n SOBS (on.( iL f o J•-•n c,
<br /> "l•I) �
<br /> q
<br /> Address: • ) l� _l d3 City, L014 uZIP:
<br /> Phoneme Date Tank Removed: -la",
<br /> *Ail A*r,F**dr*.t.F.4*,e
<br /> SECTION'3-To be1Ile clout by contractor"decontaminating tank":
<br /> Tank Decontamination Contractor: �IIL�•L7�15Pf'1) I�Q� r�-/1 G // _
<br /> Address: y06 1 �r7nrt(�1l �JP� city:l�caJ' A G zip:
<br /> c� 5 — q ' 1
<br /> Phone= .� 23 ii 3l?
<br /> F
<br /> Authorized representative of contractor certifying through signature belowthatthe tank has b en deconta nated In an approved t
<br /> manner as reyu'red by Cal EPA.
<br /> {�✓'e1�.tl/ lltle:� nnU
<br /> Name:, nIl ' Signature: Date 7 �
<br /> xn**x,F*<***;.*******t*��***,tr******,F**,t+**a****a*******,+,c•***********,:*,k*;.**;.,�***:�***,k*,a********�;�*s+4** . I
<br /> I
<br /> SECTION 4-To be signed and dated by an authorized representative of the treatment storage,or dlsposal facillty
<br /> accepting tank and/or piping. J f' �
<br /> Facility Name: II QSCO i2ba �y �'IA)) p c7+,
<br /> Address: ��nl A/, Qoir- �hC��l City:1(�/'MUfe zip: r lmSI i
<br /> Phone( T(7- �yg7
<br /> / 1
<br /> Data Tank Received;
<br /> _ J
<br /> Name:f L Int-L gltle: �f C`i u�6ignature: "L.�. �1� ate 7
<br /> F
<br /> I �
<br /> i
<br /> i
<br />
|