Laserfiche WebLink
0 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> x <br /> r <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD 4 <br /> SECTION 1 - SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is <br /> completed and returned. <br /> T <br /> FACILITY NAME: (Y111 x <br /> ® p <br /> FACILITY ADDRESS: 15-01 �• j4G1t- 7-on� ,e� ' Re(�QiJ , Ct+ - [ S3 (o <br /> TANK ID#39- TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: ! <br /> Address: City: Zip: <br /> Phone#: <br /> ( ) Date Tank Removed: <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <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: Title: Signature: 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: <br /> Address: l Svc /� 0.Ck �Q� P-A City: P l Zip: �CiSO <br /> Phone#: ( 'Z13 ) 'SCK —V6 <br /> Date Tank Received: <br /> n / p <br /> Name: Title: S✓Otl S� Signature: Date <br /> EH 23 046 (Revised 12/31/07) 10 <br />