Laserfiche WebLink
• 9 SNN?,FX DDrzw <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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. 514A1a?E <br /> s rr� <br /> FACILITY NAME:bEFFAt[F_ LOIStSCtLS 4615`LrY utt T)tSr¢iZw-nCj1 L- � 5Am JnARu�nl� <br /> FACILITY ADDRESS: 760 E 52[7"TA :FoAt� <br /> TANK ID #39 -t4j i A 5?2 2 TANK SIZE:Z0,007) 1 PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: CAL l NC <br /> Address: 0 40 ?EA6O DY ko Ali City: VAvillff Zip: 456 8-4 - 6644 <br /> Phone#: Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> �F <br /> Tank Decontamination Contractor: <br /> Address: ti82 R a�A :-,«�: .. :: Z,°F 9T�cs-� <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 /> FacilityName: E GS Z aRIC-X50JI <br /> Address: 2.S-S' PkR2 ROAD City: R1r-9-n Q w/7 Zip: 9fBQ/ <br /> Phone#: ( vel D ) 2,SS --- !3 93 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />