Laserfiche WebLink
i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ;k#itfk##itt};;tix4#4*kix#k4kii#i%;ktit#kR4*ki%rtrti#!##t#####i%!*#iii4s4kiit4#Milt#4#k#i!#4%!!s##Wti+rt#kMili <br /> SECTION 1 - Public Health Services Environmental 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 /> FACILITY NAME: \ ('; �-7� '1 /�e <br /> FACILITY ADDRESS 1`4 --o r--,as� rm` 1 V) go- Ve N s 2y� <br /> TANK ID#39- TANK SIZE: U PREVIOUS TANK CONTENTS: 'V\ <br /> l#rtii#Mittltt##kitk%#1if##4f}trtrti}#rtrti4i#iiislW#rtii4444sk##si#i###1#4##rti###ilii##iiillrtrtf#+rtrtrtrt#k!##%rtfsi# <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: 35 F�v< ALE-City: O Ciscuip:� <br /> j Phone#: � Q)g52-5551 Date Tank Removed: "2©o ( l `"f' ��J�f lJ L <br /> iii!%4llrt%#i%W rtfiiiii*ii#rt%1443##4ii#rtrtrt#44##1rt4i4i4##iiill#4%%it44*i4i###1444##*%Wrt#*rtrt#4lliltsifii+WW4i+i <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone#: ( ) <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: Title: Signature: Date <br /> i <br /> k4iti4Wrt##rt#f*!s###tlisisrtfiiiksi#kWtiii}#+t#iiks#fl#sort+i}44}##f#i#frt#in#s%+rt###kf!!irt##fitirtltsiit#t#tis% <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 /> i Facility Name: <br /> 2S 5 �� k`� <br /> Address: //'' ('� City:. 1-- <br /> Zip: �— �=y-r --- <br /> Rin#: ( ) Q `7q G G_ <br /> Date Tank Received: <br /> J Name: Title: Signature: Date <br /> 4ifMi4###ii%4!!#4+#4t*iti44irt#iii4*lf#;k44ls4lWkiiitki444144#Mi#illrt4ilt4ll}iikiiY}WWi*rti%llWlf4iltiifi%# <br /> EH 23 046 (Revised 08/13/99) Page 10 <br />