Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL EEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACHING RECORD <br /> rWTiairlrYrYirW Wwaifrtrr WW#wiTr.ririllrlWwi###.rrrt►rrtwfiiff!lWttflryWfrlwrWTirff#Wfti WTwr•..rrrr#rirri#rirrr <br /> SECTION I - Public Health Services Environmental Health Division Tack Tracking Shea shall accompany each tank affixed <br /> with its site identificatiounumber. The Tack 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: r g t <br /> f <br /> FACILITY ADDRESS: e— <br /> TANK ID p39 • TANK SIZF-: JQ-ate_PREv10US TANK CONTENTS: _�baSetil�Q- <br /> wrw#wi#rrarrrw#wrarwrwrtwr»..r.awrrtTrwrrf..wrTirf.r.frrrwrrri.wWW.rsfrwWrarr.Nrtrwrrr.r...rtr.rY...rw.r...rww <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:— e' �^� "V"^ <br /> Address:qaZt vY Ccia ` ��. # City —V, Zip: 4S'ST �Q <br /> Phone Date Tank Removed: l <br /> #.rrYwrw#rr.w4if.i........ ....WWW#��rap#rrrtOw.sigfwiwwTYY.YwwY.r..WT#r#r.rrwlrariw«w##rW Wr#yitr.lr.wrYrw# <br /> SECTION 3 - To be filled out by contractor "decontaminating fault": <br /> Tank Decontamination Contracwr:. <br /> Address: C.ry: sem--- Zip:_ G C�� C <br /> Phone A: ( 20�i ) - al 2Mt <br /> Audiorizcd reptesearazive of coawicror crstifyin$ through signature below that the tank lugs been decoetsminated in an approved <br /> ,urear as required by Cal EPA. <br /> Name: Title- Signature- Date <br /> ..r.r..r...............*..*..lwrr+rtf Wvrrrrwrowilw...wi.rww.....T+r.rrrw..... ........ <br /> SECTION i - To be signed and dated by an authorized representative of the¢moment, Storage, or disposal feraliry <br /> act..-pting tonic and/or piping. <br /> Address: 2 .��z_+j) )�- Ciry- T�r�a r 1s!zv:: - <br /> Phone A- (. '-t )�. `1 [ems P. ,pN <br /> Date Tank Received: <br /> Name: Title: SigfsaWle: Daze <br /> .........rya.....a.....rww.r.m+ra....#WWr..vwwn.r..wY....+�..Y..rw..#+#.a.nwY.. <br /> FH 23 U46 (Revised 911l"W" Page SO <br /> 90 39t?d i—,1N3WN0JIAt13 1-H9I:" ZSTSZ6H60ZT ST:91 466Ii0I;ZT <br />