Laserfiche WebLink
U <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION I - 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 30 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: S'()rJ AC T t X (YMA (aOO Zt7ter <br />FACILITY ADDRESS: 3y' �� `A✓� P('fh I c`- ��OM1 i ; �f S <br />q � ;� <br />TANK ID #39 - I(' ISs TANK SIZE: 1000 1 PREVIOUS TANK CONTENTS: (J tc2S� I <br />######Wrt####W##}##}WW##W######W#W#####WWW#W###}W#####W##W##W#W###WW######rt#}###WW#####}WWW###kWWrt####}W##WW <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tani, Removal Contractor: .')AIJ AG I LAIC. (» (i _ ) W6Frt, r <br />Address:3t'kO CfitFOr"I+/1 U_ City: Ooy Zip: 9S2 45 -91()o <br />Phone b: (fid n ) Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: �//���'�i rip, <br />Address: 9`>o AAA AjeCiry: 1I f l{ � Zip: 9503 � <br />Phone #: 4a ) y4-1— - Ps - <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 <br />tank and/or piping. <br />( <br />Facility Name: E v I � / J <br />Address: Z. eA r'r SI VA . City: of �-4'll'1' o7 ,_LZip: � o I <br />Phone H: (SIU ) ;,35 -13q-3 <br />Date Tank <br />Name: <br />Signature: <br />Date <br />+#++*#####WWWWWW##WWWW#WWs##WW#WWWWW#W#######W########}####}WWW#t#WkWW*###WW##WWW#WW#WWWWWWW#WW WRW####W*# <br />EH 23 046 (Revised 9/11/96) Page 10 <br />