Laserfiche WebLink
SAN PAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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: <br />FACILITY ADDRESS: �;/ &1/- C� ST. <br />TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br />*********************************************************************************************************** <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address:/l/_ ��IGJ�N /�//iT/ City: Zip: 9 _5_ <br />Phone #: (.1&) 44IL—& Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: 4ve`j' /y— G' City: ST705X GSI/ Zip: <br />r <br />Phone #: ( 2 Z-_Lm� <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: <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: � ,�Z <br />Address:;�M %i,� City: <br />Phone #: <br />Date Tank Received: <br />Name: Title: Signature: <br />EH 23 046 (Revised 10/19/98) Page 10 <br />Date <br />