Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> .......+......a.........rrriiwrYJiiriwiwrrr+rrJrrrwJi+rYrrrrrrYiirrrrwJ+rrWWrrirJriJWrrriJYYJrrrrrrrrirrrrr <br /> SECTION I - Public Health Services Environment& 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 /> FACILITYNAME: LIBERTY FIRE DISTRICT <br /> FACILITY ADDRESS: 24124 N. BRUELLA ROAD , ACAMPO , CA 95220 <br /> TANK 1D #39 - TANK SIZE: 550 GAL PREVIOUS TANK CONTENTS: uNI FnnFn r_ocni TWE <br /> aa+rrr.air+rr Yriwrrr+rriiiWiiiJiiiiWiriWWW+rYJr+YWWiiWii►iiiWiWJriiiYrriiiYiriiWWiiM1K.iiWWWirWiiiiiiirrrWJrJ <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: JAMES J . HOBL-1rZELL <br /> Address: BOX 30331 Ciry;STOCKTON lip:95213 <br /> Phone #: ( 2 0 9 ) 9 4 3 7 7 9 3 Date Tank Removed: _ <br /> •.a.•arrrrrarrrYrrrrrrrrrrJJWJWWJiiiiiiriiYrrrNJ+WYMJYiiiiirwiiW/rrri■irJYiiiYYYJiii VYiiiiWYJiiiYYWrriri• <br /> SECTION 3 - To be filled out by contactor "decontaminating tank": <br /> Tank Decontamination Contractor: JAMES J _ HOBLITZELL <br /> Address: BOX 30331 _ City: STOCKTON _ 7,ip: 95213 <br /> Phone N: ( 209 ) 943 7793 <br /> Authorized representative of contractor certifying through signature below that the tank has been decovatninated in an approved <br /> manner as reqT)st—T.1 <br /> d by Cal EPA. L_ ^ <br /> Name: J ?ETitle: �-C>yY�(J l Signaturo Vrlry _Date f) V J L <br /> •r+rrrrr+iWrrri+rJiiiJiirtYJJiiVYiiiY'M1ii►Wir�WwNiiiiJWJiiiiiiiiiJWiiiVi�WWJYiMiiiYQWWYYVigiiMiiiiiYiiJW <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, ur disposal facility <br /> accepting tank and/or piping. <br /> Facility Name:WEST COAST EQUIPMENT <br /> Address: 1221 TEGNER ROAD _ City: TURLOCK Zip: 95381 <br /> Phone p; ( 209 ) 668J 9378 _ <br /> Date Tank Received: <br /> r� ;1_ 8 - 02 <br /> Title-- ne __________Signature: ��Date <br /> +rri.raiiiarrr+rWJrr+s.4WririYiiiiiri+WYiJi+"+.ii+WYWiiiirYY+rririrWWrYirrirriir+iii..rriiriiWWYrrWi WYrrir <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />