Laserfiche WebLink
SAN JOlsQUIN COUNTY PUBLIC HEALTH SERVItna <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> sst/isrtrt»w»irris+rrtr►ssrtsii»ort#rrtaw#irtrts«Mr►rr#rt►4rr#sir#s»sir#►rrr+sirarirtirritr#str4siris#4sii»siiwtr+a <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: Ktng, Sa\owd RegorL <br /> FACILITY ADDRESS: Lksno We%,k ti r m7 to Roa <br /> TANK ID#39 - i H s s7e 7 TANK SIZE: .4s PREVIOUS TANK CONTENTS: L f rK r r <br /> »r#starirrr»i4r+rarrrrr4rtassr#rrii►rsrrr«Ir+wriirir►r+aro►rsirrsr4r4iirtsis##rs#a►it»»r»#srrrs►iri4rriwraii+ <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Kit Ca aPrucf'o <br /> Address: P O Box a93Gfib City: s5•ac, an Cnfe zip: 44'aas <br /> Phone t+: i Q1(. ) r.t 9-O9S LI Date Tank Removed: <br /> rsriatrsr++#r*rr4#irrrw►r+r++rtrrrtrra*►rtar**wrt#ri#rtaarrrtriiii#rrrw+4is»4rsrrwwr##44w+++carr++#r»+rt*r+t###s <br /> SECTION 3 -To be filled out by contractor"decontambu ting tattk": <br /> Tank Decomamination Contractor: P:/e Con ltr Pr- <br /> Address: PoOox 2-13484 City: Socrorenle Zip: ystaie <br /> Phone C ( 4/e a 1[$ -a's4 <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: Daze <br /> ra44wti#►r4aa»ta4wwa►arr►+aaaira4wp4i►rrrtriiir»4arar««rrstartriartrrrr###Orr»rrarrrwrrriaraarr+asiiawa#+si <br /> SECTION 4-To be sighed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: frrcKS� Tnc <br /> Address: Dss Parr Al vu City: R leh�*-Cr Zip: 9v207 <br /> Ph=#: ( Alm ) a3s-1393 <br /> Date Tank Received: <br /> Name:_ Title: Signature: Dare <br /> siirtrraatrr444airtaarrriaar4rwrrrirt4+4r4rri#+ti*#ir#r*raitsii##►ri4rfsrrri#tit►4#+»4*»r«»i#4#ssf4ra►r#4rr+ <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />