REMOVAL_2004 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD sssssrtssssrtrttt*+rttssrtrtstssits*ssttsssstsssssrtssstttssstrtssssssrtsss*sss+sss«t***stssssrttsssrtt«ssss+sssssstt* SECTION 1—SIC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: FACILITY ADDRESS: TANK ID#39- TANK SIZE: PREVIOUS TANK CONTENTS: ssrttt«*suss*tststss*stttsrtsrttss**+*srtsrtrtrttsss*srt++toss+t**ssrtrttss*rtrtss+*sssrt++tss+rtssssss+**s++sss*s+*sss SECTION 2-To be filled out by tank removal contractor: Tank Removal Contractor: Address: City: Zip: Phone#:U Date Tank Removed: ss*s*ssst*+sssst*ssstrs««sssss«rtsssssssssssss«ssss«srtrtss«sssrtstssss«sstss««ss«sssstts«sssssss«stns«ssssssss SECTION 3-To be filled out by contractor"decontaminating tank": Tank Decontamination Contractor: Address: City: Zip: Phone#: Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Name: Title: Signature: Date sssstst*sssssssssss+tstrtstts«srtts*trtsstts+sssst*sss*rttrtstsssrtt*ssss*tttsrtrtrtstsststss*sssssssssstsssrtsxtssss SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility accepting tank and/or piping. Facility Name: Address: City: Zip: Phone#:( � Date Tank Received: Name: Title: Signature: Date st«sts«sssssssssstt«s*sttssrttts*rtstsssss+sssrts*sssrtrtttrttssrtrtssssssstt*ssrt+tt**ssttssrttss*sss«ssssssss*sss EH 23 046 (Revised 10/16/03) Page 10