Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONN[ENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRAC143NG RECOR1 <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: O R ' ct A A O'A- <br />FACILITY ADDRESS: 5 6 11 E . a <br />TANK ID #39 - TANK SIZE: <br />SECTION 2 - To be filled out by tank removal <br />Tank Removal Contractor: :T- h C <br />Address: y3 1Z i s IC c-Cs^^�c-- City: lig es- S 42c • Zip 95-6 9/ <br />Phone #: () 3 - Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: W a( 6,v\ o rs C C h C' <br />Address: $ `i 3 i s ke. i . City: lA.a cst 60C. Zip: <br />Phone #-. ( %%� ) 3 ?o? - 19 8 6 <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: <br />Title: <br />Signature: <br />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 />Facility Name: E fZ i Ck6 o t^ = VAC <br />Address: a 5 5 'Pct Y` r 2>124 # City: 12; c. vnt.,d Zip: 9 y 8 O J <br />Phone #: ( 5/0 ) 0 3 5- — / 7,3 <br />Date Tank Received: <br />Name: <br />Title: <br />Signature: <br />EH 23 046 (Revised 7/10/96) Page 10 <br />Date <br />