Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <br />UNDERGROUND STORAGE TANK DLSPOSMON TRACKING RECORD <br />SECTION 1 - 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 com/pl�eted and returned. <br />FACILITY NAME: �7 G �GD tT/LIL �TZlze-_ <br />FACILITY ADDRESS: 140oftb .5Z_rQ&0EV_ z C -4 - <br />TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor:f1�A/1 slr/Y/nLo!!7�-ri <br />Address: ��� /�'/, <br />�/� 1�tE 3�.�G City: Zip: f5-2,07 <br />Phone X: &:�Pf) �_75* ��� Date Tank <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination <br />Address: /OY/3 0, 1�1�6V,4- G/OVe 4ee6 City: COZgl LYS Zip: <br />Phone N: (mel-) �7Cy �Gf07 <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: Tit1e:��CO� 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 <br />City: .-- Zip: /✓�17,( <br />Phone q: <br />Date Tank Received: <br />Name: Title: Signature: Date <br />EH 23 046 (Revised 9/11/96) Page 10 <br />