Laserfiche WebLink
i <br /> ENVIRONMENTAL HEALTH DEPAR <br /> SAN JOAQUIN COUNTY V�fflVED <br /> Telephone: (209)468-3420 Fac: (209) 468-3433 JAN 18 2011 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECO <br /> SECTION 1 -- SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank a uce1�'Iss`�ite <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 <br /> completed and returned. <br /> FACILITY NAME; <br /> FACILITY ADDRESS: ( <br /> TANK ID#39-d O TANK SIZE: PREVIOUS TANK CONTENTS: �'(� g✓�J 67, <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor- fes <br /> Address: ,g ©/J / Zip: <br /> � City: <br />�. Phone#: i���/ 1 4 � f Date Tank Removed: <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor:� o <br /> Address: /'O l <br /> r City: zip: <br /> Phone#: <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 />` Name: / , _Title:Cpt���/r✓f'�/ .Signature• Date 1O <br /> SECTION 4-To be signed and dated by an authorized representative of the treaLment,storage,o disposal facility <br /> accepting tank and/or piping:.. <br /> Facility Name: OE/C i <br /> Address: Z City. C62Dpd Zip: 9 5�,2 � <br /> Phone M ( en�) <br /> Date Tank Received: "-- 3-- <br /> �a7_Signature: D <br /> k <br /> t <br /> } <br /> EH 23 046 (Revised 07131/08) _ 10 <br /> E <br /> s <br />