Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> »wwwsstwwrtwwrt*Mrt+ssrtssslrrwlswttt*w*ss++sss*ssssss»ss»w»+sss»shit*4*i*+*#ssss+s+++s+++444»r444+4rtrt4k4k#4#+# <br /> SECTION 1 — SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is <br /> completed and returned. ///G.U/LL1iV ��•9 L �ST9T� /�d�S7 -✓rf <br /> FACILITY NAME: (Z /N/n) G F //)(15417% GO 7- <br /> FACILITY <br /> FACILITY ADDRESS: O Z/ 15t S. G L/_)ORJg Did <br /> TANK ID#39-O9'1 1 S q.0 TANKS=: ZQOPREVIOUS TANK CONTENTS: t/j& <br /> **ss*s»rttwwwwsw+*ssss!*s+ww4+**+*ss**ssssss+swwwwtwtww*st*s*»+ss+ssww4+*}+s4i**s++s4w#####+4#4441+}!+4}+s#* <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 2 � — 016 <br /> Address: 7 O 13 o x . 35 7 City: Z-VID Zip: C1S�� 5/ <br /> �)Phone#:( yjZ / iGI Date Tank Removed: <br /> SECTION 3-To be filled out by contractor <br /> "decontaminating tank": <br /> Tank Decontamination Contractor: //N) DL /, <br /> i /G. <br /> Address: & 90)(tr � 7 City: L400 Zip:- 25'oz 7"/ <br /> Phone#:(C20% 2- <br /> 97 � <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�/� 71w //t` Vs— Title:;!?iG� Signature: Date <br /> *rw444sss»s»ww4ww+s+ssswwwwwr***sw+s++++###}#}*ss*ts+sssw++t+rtrtw4itssssssssssswwtwttsssstss+sssstssssst*ss <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. f� <br /> Facility Name: S C—J7�I TZ 4& J 7Ecl gac,7S <br /> Address: <br /> /ol DOD /mol SDir( C3L v/� city: Cott Joi-1 Zip: 0/5r Z <br /> �y <br /> Phone#: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> 4isisi+i4++*#»+»t+kklsili!**i+*+++»»+++ort+wsw»wwww#tt4*itW*ii*+Wrt+k+#444tOrt4lk+lrti!lii44W+++++»rtWWi4iitti <br /> EH 23 046 (Revised 12131/07) 10 <br />