Laserfiche WebLink
l0. OG OOODOOL VULUM= DArI1bIH rHun G1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV1....S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> \!a\\\!\\\\\\r\\RRfrRRt.RRfwVYIrIR/Iia.....0...w...Y.wr.YR.w\wwr.ww.R..f.R.rwMwwrR.M1fRIr...1f..RarR.wa! <br /> SECTION 1 - Public Health Serviem Environmental Health Division Tank Tracking Shea shah accompany each tank affMcd 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 respomtble for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: ��C1d.�Q/I1 <br /> FACIIJTY ADDRESS: r vii /7! Y r 1Gf c G <br /> TANK ID 039 - 5153 -7I TANK SIZPREVIOUS TANK CONTENTS: <br /> PrraLHo o ww.r t.w..wV.wwwiLw..............Ya.oqr 0000.10 r......Ylf.a!!Mf.....r......Y...Y........ <br /> SECTION 2 -To be filled out/by hank removallcc(�ontrbetor: <br /> Tank Removal Contractor: _ /7C�a�br- yC-ZED n <br /> Address: 4v5 , kmj 04 Wi z Ciry: �G l�0�A/� Zip: J SZ4DS <br /> Phone r: `/f ) +b7 Loty <br /> a Date Tank Removed: <br /> ra..............*0www.R..r.r\.wr..a.a.r....ww..ww...................•4.•........ru•aw.........*.......awaw• <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decont2minnlion Contractor: mo <br /> _ f I, 4%-,64_x^- 1r7� �I�llYyl1Q11 Pl'74 <br /> Address:-40-s- 1V gl, w I J.l 1t) m L City: Zip: /s 2 D <br /> 51- <br /> Pbooe r: ('�4 �17/—IP-0 0 <br /> Authorized representative of contractor unifying through signarure below that the tank has been decontaminated in an approved <br /> manner,as/required by Cal EPA. <br /> Name: f/I Uv,�- � Tide: �— sigantre: / <br /> Date <br /> ......Y.....w.r........f.................Rr.♦.........Y......\....•.....Rr.....r...r.........R......ra..• <br /> SECTION 4 - Tal*.signed and dateLby_an authorized repromatative of the zeatmcnt, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: W � aL.pi�flpl � <br /> Address: P� �17,� Q7i�, S�[� L � i�: �/moi Zip: �61 <br /> Date Tactic Received: l/ <br /> Name: 2 Tine: Signature: /�C Date <br /> 76 c <br /> .wwwa.\ra..................Y.vara...a.rf.rar.aaa............................r. ......r\u........auYY <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />