Laserfiche WebLink
SAN10 A Q U I N Environmental Health Department <br /> COUNTY <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 — SJC Environmental Health Department' s Tank Tracking Sheet shall accompany each tank affixed with its <br /> site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 <br /> days of acceptance of the tank by the disposal or recycling facility . The permit holder is responsible for ensuring that this <br /> form is completed and returned . <br /> FACILITY <br /> NAME : <br /> FACILITY <br /> ADDRESS : <br /> TANK ID #39 - TANK SIZE : PREVIOUS TANK <br /> CONTENTS : <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: L . C . Services <br /> Address : 3887 N . Valentine Ave . city: Fresno , CA Zip: 93722 <br /> Phone #: 5( 59 444- 1730 Date Tank Removed : TBD <br /> fitfiRfiR*RfiRfi*tfi*#R*RRfi1M*fiRkRfififi*fitR****R#fiRk****44**R***R*Rfi*fi***t*##t#t*#tt##*####444*#*k#***4*4******* <br /> SECTION 3 - To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination Contractor: L . C . Services <br /> Address : 3887 N . Valentine Ave . city: Fresno , CA Zip : 93722 <br /> Phone 0: 559 444- 1730 <br /> Authorized representative of contractor certifying through signature below that the tank has b econtaminated in an <br /> approved manner as required by Cal EPA , <br /> Name : James Otto Title : Project Coordinator Signature : Date 12 /09/2019 <br /> **# *#***4fi*******kk***#********* <br /> SECTION 4 - To be signed and dated by an authorized representative oft reatment , storage , or disposal facility <br /> accepting tank and/or piping . <br /> Facility <br /> Name : <br /> Address : City : Zip : <br /> Phone #: <br /> U <br /> Date Tank Received : <br /> Name : Title : Signature : Date <br /> 9of10 <br />