Laserfiche WebLink
0 <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 />SECTION 1 – SJC <br />.Environmental Health De ............... <br />*••••••*.*.�.••• ......... ......"""...... """".... *.. <br />nt <br />nk <br />identification number. The Tank Tracking Sheet iseto be areNmeddto Sheetgthe Environmental Health Department within 30 days site of <br />acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed <br />and returned. <br />FACILITY <br />FACILITY <br />TANK ID #39 -Y—O— % TANK SIZE: ,'PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: 20 3 X 3.5 7 City: e—' e) / Zip:_ C/S ..2. <br />Phone #: L1057) )_ 364� 6 / 7 s Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor:)� <br />Address: e d [30X �5 % City: G v/ Zip: <br />Phone #: L —6 g - <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:MAZW <br />SECTION 4. To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />1 <br />Tn1KS 7,0accepting tank and/or piping. <br />Facility <br />Ma <br />Address: <br />n/ ty zip: <br />Phone #: (z 0 <br />Date Tank <br />Name: Title: Signature: Date <br />fl 9f)f2ES S <br />3 P-lo„1 e s# <br />Sc-hrNrTzA /Z Sri L PR0D✓c7'5 <br />/ LC,Ur)- r0GSd/v7 f20>4v iR4,V)6N0 Ct9iJ6,aA <br />1W6) yes <br />G <br />To /we-, <br />RrJJAf'Ss 9 % 9 $, /gas 7-1-0 j2,heFJ <br />EH 23 046 (Revised <br />9 -7 75`L <br />