Laserfiche WebLink
SAN JO.,_,JIN COUNTY PUBLIC HEALTH SERVII <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> M#MMMT:rMwrrwrrwrrtrwwrrtrrrrrwwrwwrr##rrrrwwrwMwrrrrrr#rrarMrrrrwMrrrrrrwrrr+YwMri#rwrrrrrMrMrMr#M###iwrtrrrrrt <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: or <br /> FACILITY ADDRESS: ,344 <br /> L LTANK ID .#39 - 1,7CJ - cj TANK SIZE:—4PREVIOUS TANK CONTENTS:�IO��(Y <br /> rrM#r#rwr#Mrrrwrrrrrtrrrtrrww.rrrrrrrrrwMrrrrrMwwrtrrrwrrwwrtrrrwwwwMrrr+rrMwMwrwrrrwrrrrrtrrwrrrrrwrrrrMrrr#rrrw <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: T <br /> Address: 7 Or �✓� City: iC � Zip: <br /> Phone 4: ( �-t/9 ) 5'1q--134'1 Date Tank Removed: <br /> Mrrrrwrtwwwwwrtrrrtrrwrrrwrrrrrrrrwrrrwrrrrrrrrrrrrrrrrrrrrrrrwrrrwrrrwrrrrwrrrrrrrtr rrrrrrrrrMrrrrrrrrrrwrrrwr <br /> SECTION 3 To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: D' <br /> Ciry:-AAM Zip: grn.22� 2 <br /> Address: .1� <br /> Phone ,#: ( .oq ) <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 /> _ Date C <br /> Name: C ,` it T Title: �' �' Signature: <br /> wrrrrwMrrwrMrMrM#wMwrMMrrMrrrrrM#yrrMrMrrrMwrrwrw#MMrMMMM#rM#rrrrrwMrwwrrrMMM#rritrMrMrrrrrrMwMMMrMr#rr+MrMrr <br /> an authorized representative of the treatment. storage. or disposal facility <br /> SECTION 4 - To be signed and dated by <br /> accepting tank and/or piping. <br /> Facility Name: � " <br /> City: Zip: 3� <br /> Address: <br /> Phone #: <br /> _::7Date T �ived: <br /> ' - <br /> Name ^` • - Title: Signature: T' Date <br /> rr rM MrrwMrr#riMM..MMrr#r#rrM IIM#MMrMrfMwwwMMMMMwMrrMrM#rMrirrr#rrrr#MMM#MM##wrwrMrrMrrM#MwMrMrMMMr##M#M <br /> EH 23 046 (Revised 10/19198) Page 10 <br />