Laserfiche WebLink
d <br />SAN JOAQULIi COUNTY PUBLIC HEALTH SERVICES <br />EN'VIRONMENT-,kL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACTaNG RECORD <br />zxxzxxxxaxzzxxzacxxxzxzxzxzxxxxxxx:zzzxz::xxzzxxzxxxxzxxaezzxxzzzxxxxxxxxxzxzxzxxxxx zzxxxzzxzxsz. z xzxzx zaexzz zea <br />SECTION 1 - Public Health Services Eavironmentai Health Division Tank Tracidne Sheet shall accompany each tank ar±xed <br />with its site identification number. The Tank Trac.,dng Sheet is to be returned to Pubiic Health Services =vironmentai Health <br />Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsibie for <br />ensurinz that this form is completed and returned. <br />;: CIT TY NAM <br />ACILITY ADDRESS: � 2 3 <br />T.=L-,-i ID 139 - <br />7A\i; SIL= o®® PPZ-VIOLS TANk CON:':?\'TS: 1 w o <br />xxxxx-xx---------x-xxx--------xxx-xMxz-xx-xxx------x-W--xxxxxxx-_x-xx-----xxWzx---------------xxx <br />SECTIOi`i = - To be filled out by tank removal contractor: <br />Tani: Removal Contractor: <br />Address: f O. 023 g Cit;': Z; <br />?honer-: (,tD cl ) � (o 2 - � 3 7 Date Tank Removed: <br />953 8/ <br />------------------------------------------------------ = --------------- = ---------------------- = ------------- <br />SECTION <br />xx-xx -----xxffixx-xxxxxxxxxxx-xffixxYxx-ffixxx-xxxx-x--x-x=zxxxxxxxxxxx-xx=-xxxx---xxxxxx-x-xffixx-=-xxxxx-x-x-x- <br />SECTION 3 - To be filled out by contractor "deconraminatinc, tank": <br />T an:1 Deconra=ization Con=. -=or: IV <br />AddreSS: �S W=:—, lL� �/) Ci -LY: <br />Phone 1: 3 % <br />authorized representative of contractor =—dfvine through. signarr-e below that the tonic has been decon inated in an approved <br />manner as required by Cal EPA. <br />Name: 9,4 (? RX ks /G !2 Title: �.u.a.e,e�'.v�c�Y Signature: Date / 9 <br />----xxxxxx------xx==xx-xxxx,�xx �x,��xxxx,�x,:,�x,�xx,�x� x,�xxx�xxx��xxxxx�xxxx,�xx-x-x-----xxxx-Rxkxxxx�xR <br />SECTION 4 - To be signed and dated by an authorized representative of the tre :linen, storage, or disposal facility <br />accepting tank and/or piping. <br />r aciliry Name: <br />AddPeSS: <br />/ O QCR-Cil/l <br />u <br />City: �( (6 Z:D: 7 J�3 S-1 <br />Phone -. <br />(coq ) <br />L G �'' 4 3 7 F <br />Date Tank Received: <br />Name Title: <br />Sienature: <br />Date <br />x¢zzrexzaje qezie hickz:zzz�xxx:xzxxgsyezaxzakzxai gexx�!eaacxzkale:::xaieaz:zaKais;she:ziezai�sakxza�ycaigoxxzzzz�e Rex�peaexx�Kaaxaezapm.z ae zasxxzxaje ac ap aiea <br />E -H 23 046 (Revised 9/11/96) Page 10 <br />