Laserfiche WebLink
SAN JMQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> #+k##WW#Wrt#rtki#rtWWtikk##Wttt#+#rtrt#+Wrt####i##++##t+#i###Witt}+#rt+W##+4##ti}##WWW+rtW+ti#k#iiki*#rt##W#t+##k#}** <br /> SECTION 1 - Public Health Services Environmental Health 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 recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: Y( / ; <br /> FACILITY ADDRESS: 1- ,:5 � (I <br /> 'LANK ID#39 - TANK SIZE: ;� �,^�;�; PREVIOUS TANK CONTENTS: <br /> i}}##W#W+##kirtk#+rt*4#+kt##ki#irtW##rtW+#it#iit}kiiirt#*#W#rt##Wtrt++rtrtrt+++rt44i#iii#*itiikkt4#i4it*iik+tWtt4 Wrt+trt <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: � ' �ri,�' �Y (�� (` i _ ��1_ City: Zip: [�� ;}C <br /> Phone H: (. /} ) ��ll S "5�G _�� Date Tank Removed: <br /> i###irtWWrt++kkit###k+W+kitikk*rt*W##rt+W+Wrt+rt+#t#t##ikittii#ti#i#}ik*#rt+rtrt#rt*#WW**#*W*#W++#iki*i}+tiiii4ti#t## <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone q: ( ) <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: Tide: Signature: Date <br /> *}rtWrt+W#iii#rtrtrt+WWt+t##++rtWW+tii4}i#rtrt*#WWtW+W#Wt+ti#}}W###*WWW}+++W+##rtit#W#++tt*+ti*Wish#4tiiW+trt++#+Wrt# <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: City: Zip: <br /> Phone N: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ##WWti#k##Wkk+ki##W}Wt#+WkkW#W#W#Wki#i##Wrtrt####W##}###rtWrt#+W+WW*#i#*}###kis#i#W#iit##++t#tWrtrttk+tt+4+WW+* <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />