Laserfiche WebLink
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. <br />FACILITY NAME: <br />FACILITY ADDRESS: 7 <br />I <br />TANK ID 1#39 - TANK SIZE: , 3 QQ O PREVIOUS TANK CONTENTS: <br />. xae ae ae ae aexac ae ae�ae aeae aeaeaeae aea:ae aeae�kaeaeaeaeaeaeaea=aeaeaeaex>k ae �eaeaeac*ae*aeaeaeaeaeaeaeaeaeaeaeaeae ae,eaeaexaeae ae aerieaeaeaeaeae aeae aeaeaeae aeaeaeaeaeaeaeaeaeaeaex�acaeae aeaeaeae�**ac ae is <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: <br />Phone #: ( ) <br />Date Tank Removed: <br />City: <br />Zip: <br />a<aeae M k'�ae ae %�Ie ac ae ac ede ae ekv,.e ae ae ae ae aeae ae i ele aeaeae a: aeaeae ae aeaeaeaeae ae ae ae �Peakede ae a<a<ae aeae�F ae ae aeae ek # ae arae ae * *aeae arae ae *ae ae a<eK ae xa: aeae ek aeae �Ka: * aeae a¢ as aeaeaeaeae ek efe ae ale ae ae * ae ae* aeae M ac <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: f V <br />Address: is c— L(l ^ , City:_, ._ Zip. 9S2 <br />o <br />Phone #: (,10 C? ) 40 " (i► J 3 7 <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:.144 e Title: Signature: Date '� // 90 <br />/ <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 />Facility Name: <br />Address: <br />Phone #: ( ) <br />Date Tank Received: <br />Name: <br />Title: <br />City: <br />Signature: <br />EH 23 046 (Revised 9/11/96) Page 10 <br />Zip: <br />Date <br />