Laserfiche WebLink
SAN JOAQLT'4 COLNTY PUBLIC HEALTH SERVICES <br />E"N"MON"WNTAL HEALTli• <br />ARM, <br />r , � <br />SECTION t - Public Health Services Environmental Heaith 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 rccyciing facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAIME:� �� ?%��✓�- ry c_ _ _ <br />FACILITY ADDRESS: i. _)' G ,�� 2 -.,,�,•-� �t A4 <br />TANK ID #39 - TANK SIZE: 6 PREVIOUS TANK CONTENTS: i;�i E'.; --<7 <br />+rhe+k***s##*+R«v*wwwM�wNep��hNeq�«�m*«,s*ss«,sr��r«#Msww#«*+�+a+kNsawexr a�xo##*,aM*�kN+ww*****ww+swu*..a�www•rwwww*w+ka*asw*ta*www va a xw <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tani: Removal Contractor- <br />Address: <br />ontractor <br />Address: /'/-/y h`%� �r_� City: --.Zip:. <br />Phone Date Tank Removed: /.ZAr <br />w�sW*w�Sep+N+M+u«*#n«#*##«#yaw#«wp.*M�.#«#aux,eww+h#«+pycnswrs*�aaw#srt+a«*k�c«*�cw+kw*�.+M+h+ktwwwwwswwwW«wwwwwwww*+k*ae+►**wwxwws:. w,mwM <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: �> a� �e�iy� -,PF-c, ✓/� <br />Address: P <f . ,�� ���r �� F _ City: Zip: G -' y <br />Phone <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: IVTitle �ht- Siznature:;- , � Date <br />. P <br />L✓ <br />*«wM�wW1M W *�*�*###««««#ahMMwMt k#«�«««gtia.yWiN �+k�M#k At«##«###+ReNAtWN'dek�*yk:e«#«##wwyx kwaaW7RwfM«k M««ar««yt««w «w4f+kw'N'O'+MM roew:k nu94.dMwM <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:vjj�— City: Zi <br />Phone #: <br />Date Tank Received: <br />Name: Title: <br />Signature: Date <br />EH 23 046 (Revised 10/19/98) Page 3Q <br />