Laserfiche WebLink
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 Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is <br /> completed and returned. <br /> FACILITY NAME: = /2 E 6 k L S' S V, <br /> FACILITY,A)aDRESS: ��() Meg ��/� �� <br /> TANK ID#39- TANK SIZE;� :Q ,_PREVIOUS TANK CONTENTS: (-1)LF�J� <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Q } <br /> City: Z®/--'2/ Zip:--9 �,yZ 7 / <br /> Phone#: ZG'ElZ If/ Date Tank Removed: <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: �? ��y' /�C. <br /> Address: 2r 6 C2ra5 City: 6001 Zip: C ...� <br /> Phone#:u& Z 0 <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 /> NameTitle:<=�k2 '�Signature: <br /> Date <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: /t <br /> Address: % f(� S T� C2� /� Cid, Zip:_! <br /> Phone#: ( � ^ zs <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 07/31/08) 10 <br />