Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD 0 E C 2 7 2004 L <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 M days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed <br /> and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: ✓1/ C ✓YC ©/div/d� S <br /> TANK ID#39- TANK SIZE: PREVIOUS TANK CONTENTS: CSN K <br /> E i#f#ktlflit#iW##ik#iff#W##kf#ff##W#iW#ikW#iW##k##Wk#W#iW##iki#k#ifkf#Wff#f##W##ik#{W#k};k###iW##WW#iik#fikW <br /> t <br /> SECTION 2-Tobe filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address, ,, / /(/ y// eO- City: Zip: S �C <br /> ( Phone#:L-1�'c/) �(j 69-,6^1 7S Date Tank Removed: <br /> j SECTION 3-To be filled out by contractor "decontaminating tank <br /> Tank Decontamination Contractor: G9// <br /> Address:___�.3 �� /lc��J N /2� City: , Z)Z Zip: 25 o/ `5I� <br /> r <br /> Phone#:( <br /> 2-C) <br /> C/) <br /> s <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 /> � 2 <br /> Name: ,l1�/�/T7/->J/ Z�1(&Title: 2 Signatur ct ate 3 rij <br /> iikkkffiiii####kkfkik#ikfiiW#kf##W##ki}{kk##W##kW#kifk}#fk#ik## ti# k}##kf#k fkk#i}�#if##kkkfif!#{WW;iW# <br /> SECTION 4-To be signed and dated by an authorized representative of the tre tment,storage,or disposal facility <br /> accepting tank and/or//piping. <br /> Facility Name: —e '� �' f <br /> Address:,Z�6)y� ��LS City: r'n/2/7fJU/I Zip: a/ <br /> Phone#:( q/6 ) 96-5 %�1 <br /> '/ <br /> Dau Tank Received: n � � `t <br /> Name � i 0/4/ ?Tit1elQZ-Q �L�1 ' l Srgnature: DateL) - �^6 <br /> iiitifiikikWiik}#tkiik##ki W#ki#i##kk#kik##kW#kf#iW#ik#ik#kRW##kW##kW#ikW#k##ikifkitWftiW###i###i###kW}iff <br /> EH 23 046 (Revised 3/15/02) Page 10 <br />