Laserfiche WebLink
SAL` JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENMONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ■e*+*yt*W*#*x+Y:***x****rx*y�**r*x�*xx*******r**�M*x**x�r*****�Fx****+Ie*xx�M**s*aea�xx**s***+Ierrx*s***M:M*xr�c*********�* <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: n <br /> FACILITY ADDRESS: 2191 Navy Dr . Stockton Calif <br /> TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br /> *►*rrs*****a�x,k*,�c***ale+k+tk+s:sae�Merrx�k**�ey*trs�airwr*N*�+r*yf�ae*rrriYx�kwca�**Fwe�e�e R*ye*,xxx*x R��h***s*Fxfeye ileMele*f:***fir***xsrx <br /> SEC'T'ION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: P . O. Box 737 Ciry:Vailey _Sprin giP: 95252 <br /> Phone #: (209— ) 931-5513 D ate Tank Removed: <br /> SEC'T'ION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Satre as 2 <br /> Address: 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: Signature: Date <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 /> Faciliry Name: <br /> Address: City: Zip: <br /> Phone #: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> x*�*»*r*****�*:*************:�r�rrxMexrrrrxxxrx****r*+*x*xs*s***�k•*+r*x*srx**s**�*k*sr*�xx*rrx**at*s�*ter**:** <br /> EH 23 046 (Revised 9/11196) Page to <br />