Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH*VICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSMON 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_ 3.0 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: 2Z2 65 V <br />TANK ID ##39 - ' 01 TANK SIZE: k O 4000 PREVIOUS TANK <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: W U I +cm m n r,; r% ccC- <br />Address: 1PQ 6 .. <br />Phone f#: ( 71e.) oZ ® ® 8 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Mo <br />Tank Decontamination Contractor: yl cr YL 1 IV = C <br />Address: Ro (a,67,/, CO. J City: 6u, Sal, Zip: 9S 6 <br />91 <br />Phone #: 714) ;_?'oZ— I <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: <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: 5Oa5.7 = u a" /Y� C22 <br />Phy5ieol Q Ciry: Z(> > Eck Zip: <br />Address: / S Q GU . s <br />Phone #: (v`? O ) 668— 93 3' <br />Date Tank Received: <br />Name: <br />Title: Signature: <br />EH 23 046 (Revised 7/10/96) , d Page 10 <br />Date <br />