Laserfiche WebLink
SAN JOAQUIN COUNTY VUBLIC HEALTH SER_1r?CES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> *********************************************************************************************************** <br /> SECTION 1 -Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: �� Cw <br /> TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br /> #qKl �JL_- <br /> �ION -To be filled out by n r- <br /> oval contractor: <br /> Tank Removal Contractor: <br /> Address: City: Zip: <br /> Phone#: ( ) Date Tank Removed: <br /> SECTWN-:� To be filled out by contractor"decontaminating 120k": <br /> Tank Decontamination Contractor__2� �R) <br /> Address: City: Zip: <br /> Phone#: ( ) I i <br /> Authorized representative of contractor certifying through si ture below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> CECIO -To be signed and dated by an authorized repr entative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: <br /> Address: City: Zip: <br /> Phone #: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />