Laserfiche WebLink
12/20/2006 12:49 2094640138 ENVIRONMENTAL 'IEALTH PAGE 10/11 <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 /> r•Yr!•r Yt riM ilbrr•YtY•r•,t HirbbrraHb««Ygbq•atrr«•baM•Yrrrr«rrtYbr•i H•IAN««b blit YM«t bttr,•• <br /> SECTION 1 - SIC Environmental Health Department's Tank Tracking Sheet sball accompany each tank affixed with its site <br /> identification munber. The Tank Trackin�Sheet is to be returned to the Environmental Health Department within 30 days of <br /> acceptanec of the tank by the disposal or hecycling facility. The permit holder is responsible for ensuring that this form is <br /> completed and returned. \\\` <br /> FACILITY NAME: -SAVLAAkieAp p�4 <br /> FACILITY ADDRESS: ZSly' ,.l GIuP�T <br /> TANK ID#39- S S I TANK SIZE: T6 DCA,, PREVIOUS TANK CONTENTSACA054 6,.'4 <br /> ..Y♦tr blrbrbuii•urlprq«brr rr••burr«rrrrr«br•r«r«rr+re««rib!«b+ra rYrr b•r•brtbbb•r+.•r♦r+•r <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank RemocvalContractor.�oc5k5! iant15Teiwttiz- <br /> Address <br /> Pbone#: ( ) o"C - 6 S33 Date Tank Removed: <br /> !t•.r•Y♦♦Mr,r•t«•rirr••rribarrabbbrra•b YYYrrarrab«r•bbrHrrrb HbrMHr•••«b•IYabi•Hr•♦rr q,q <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tonle Decontamination Contractor: V tCE oa CmL <br /> Address: gt9� C_lh(1DsLCi <br /> ry _Zip: <br /> Phone#: <br /> Authori2 d rcpr s ntative of contractor certifying through signature below that the to h sen decontaminated In an approved <br /> mao PA. <br /> Nam Tide: — �igna <br /> /pp1�� DateyZ-?i�-Oto <br /> rt.r• ♦ +rr•r•b.•r•♦rtrbrwrr..t••..•rYr.bbtarrrYt.+b rrrb err R►t.Y brrrti+►rtar«rrburt rrtttbb,.ar•' <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. <br /> Facility Name: <br /> Address: Z-S—/!!F r7VO t ,A, ,n i r City� � Zip: ys�� <br /> Phone N:( 9 <br /> Date Tank Re c ed: <br /> Name: / lZe Titl :/l e4 , Signatu `+ t <br /> •.Y•iNtr tatp•ur•+b«bra ra Yr••,•brbrrb!•rr•u4Nrbp r!r• N <br /> itb•bblriiYYY+rt+br«r•irrtb.rrr+i•!r <br /> EH 23 046 (Revised 11/21/06) 10 <br />