Laserfiche WebLink
EI'�V]'[]E + NT�►!IEl`TT :0EALTH DEPARTMENT, <br /> : .SAN J6A.QMN COUNTY <br /> '.TeIePh0►ne:'(249)=ISS 3420. Fax: (209)4SS 3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD ', <br /> . .l•1^k#i l#\Y•ft'A#Y A"*.*4#Y'lY•#1'1•A'tY '-**AY' A#U.•-*t**4Y#i^k Y•!•k•k 1'A.YI <br /> SECTION-1 -- SJC 'Environmental Health Departriienft Tank'Tracldng Sheet shall accompany:each tank affixed-wlth Its site <br /> IdentItcatlon number. The•Tank Tracking sheet Is to he returned to the Emdronmental'.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 /> FACILITYNAME: \C-co p' n <br /> FACILINADDRESS: SSD NA), CCS R �- C f <br /> 651 a3 DIj <br /> TANK D#Ki9- r_:; ?-/�� TANK S IZE: 2`Z 1� PREVIOUS TANK CONTENTS: Q�eSel I &-Aso t I n e <br /> "lC7C'�f1S'%:i'YAC:��%'�7CX7f'�iE'Y�'.%X:E':f:I7Y:F'�'7C7fVS'7Ctt'j:7fl�lf`.{"�C7Y:FXV'7CF[C'<�:3J*�jC.F7F�:7C'k.'iC7C1FT':<%7F'Jt:C:�'SC�7E'XYC:t':�'�."�S�'XiC��7C�:'IC,F'IC'�T.31�C'kt'G*9Tl':k0i'7c7Y'�'7:'iC�7CX'if'�1: . <br /> SECTION 2-To be-f sled out by tank removal.contractor: <br /> Tank Removal Contractor: w e_Y dA- C0. <br /> Address: 1"•o• b 1`i 3 City, LDA 'ZIp: 11��2UO <br /> "Tank �v<Phone#: Date <br /> ':FT.��:i'C'I{'iF:CFft)FRSC:4 T'fY:'l{"R:f:C�C�:'IY'i4'k1F:F I:)f T.)l'iFT1F'ItT%"iY:\'T:F:CiCX:C:CjC%:C1C)[tE':�:E�:{'�'7F1C�'.CT']i'!�C'R:C:E:F�i1C:��C'iCT�:�!'lCt1C'iCx"F 1Flf:C:S iE J'CT.h'I:T.Y�.7E•'iC SC•iC'�':�Y')['ir <br /> SECTION.:3-?o be•1111ed Out by contractor"decontaminating tank": <br /> 'Tank Decontaminatlon Contractor: • 4 bvY�S �'Ai 1l I CQ� �1 G B <br /> Address: �06 - 1'- �- o o&- l 81 JPj City:6.0\r A G zip: HOZ If� I <br /> I <br /> Phone :) 6)-2, - Nq)O <br /> Authorized representative of contractor cerMyingthrough signature belowthat the tank has hen decontar nated in an approver! <br /> manner as required by Cal EPA. ^ <br /> Name:. »� � � l/VeY / 11t1e: �_f��i�QQ, Signature: __Date' 7 <br /> ie:t:6kie•ieY:i•k%xxie:e9efrii::k�i••k;F%xxie�k k:Fie�'kkie@tkieY k:bt:cx'ieoY kxtieie ie*'ie:ei:ic•koi'•kaF:Pick*:'etFdc*•kat�ek*de:ir�tiek:Fx�*n4dede:k*•ie�eie ie•kk4:�etir-k:k;Fk*'ic <br /> I <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tank and/or piping. <br /> FacliltyName: ��(SCD KoQ� �q✓1�Q7/� <br /> ��� gg <br /> Address: �P){�� !V i Oa s_r_o &rd City: ._t 0y-1y1 fe zip: q 1MS ) <br /> Date Tank Received: -- <br /> Name: Title: Signature- Date <br /> I <br /> • i <br /> i <br />