Laserfiche WebLink
11 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />'UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />41 IR * 1, ** *+4; * k * * 4 * * ** 41 * * 4 * * *** * * * * 4� to :s 4: 41 * *;� * * ft 4 414 lk 0 * * 0 * * * * 16 * * hk * * * * * * * * * + ;� * 4 * * ** * ** .1, *4 14 At <br />SECTION I — SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank alfixed with its site <br />identification number. The Tank Tracking She& is to be returned to the Lnvirosundatal Health Department within 30 daLs 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. <br />FAULITY NAME: Haight Road TaW< Removal Project, APN 061-150-3 - 8 <br />FACILITY ADDRE SS: 6426 E. Haight Road, Lodi, CA 95240 <br />TANK ID #39 - .—TANK SIZE. 500 gallon PREVIOUS TANK CONTENTS:__— Fuel <br />44 70 * 4L* 4: -P 44 q1 At 4 <br />SECTION 2 - To be filled out by tank removal contractor: <br />'Panic Rernov;tl Contractor D & S Dragline Service <br />Adch-ags: 54.0 F Street City: Los ffiuios Zip: 93635 <br />Phone 4: ( 209_).__ 826-4252 Date 'rank Removed: <br />09 ** A** *****:i *4; ;ti i%*4 '4**11t W,* * * i,*:R** :P:O ;Wl; **;N $ 4;W 4 *10 *** * ** 4** ********4; *4 ;I: $444 0* **q: *4; * *14$44*44 <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank DecontEanination Contractor: D & S Dragline Service <br />Address: 5401 Street City: LOS Banos zip: 93635 <br />Rhone #:( 219 <br />826-4252 <br />Authorized representative of contractor certifying through signature below that the tank has been decantaminaied fti an approved <br />mariner as required by Cal EPA, <br />Mum: Title: — Signature: llate <br />At 6y 9, e tii W ******** **** *** $ ** ; ***W* ** * 4 ** *4 * 41 * *41** Mq***M * k4**+ 4* :k*** * *10 * q� * * * * **4 ;h*4 4,k* <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal fficility <br />accepting tank and/or piping. <br />Facility Name: West Coast Eqaipmeiit <br />Address: <br />Phone #: ( 209 <br />Date Tai -dc Received: <br />a <br />T�ivfnrdr Q 4q 12 SM <br />11UL Da City:Zin: <br />668-9378 <br />Mune: "ritie:__ Signature: __---Date <br />;k * ;i;* * * 4; ;0 * * 4 A; 4 ** * * ;k * * ;N - * * 4, * * 4 * + LF :E:4;+ ;k* t * ;0 * ** * ** At * * * * * * * * it *+ 4. * + -#* * :k;k* * * * * 1: *:* 10 * Ep :� * * ;t; �*- * * 4; * ;R ;k IN* At At *,R * * It * *W�-* W $IN * <br />Ell 23 046 (Revised 8/3/07) 10 <br />