|
S IN JOAQUTN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION
<br /> L'vI)ERGROUND STORAGE TANK DISPOSITION TRACKING RECORD
<br /> *,k**********=**a**a1****a.****-*1*11** 1*++,k*r*+r*.,ri*##*********
<br /> SECTION I - 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 dans 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 NAE: tn
<br /> �Vl� �+�I�T ( Yc ly h� tot �+ aY -��c � r
<br /> FACILITY ADDRESS: S o L4
<br /> TANK aN
<br /> ID #39 - TAK SIZE: 55 D—Ja I`11
<br /> a hs PREVIOUS TANK CONTENTS: �A S -h ny
<br /> *,.=#a.:,t=�,i:,...»#,.,hoc,F,s=*=#*wv.,ka.,r*a.*„a,n,►,.r,ks%,.,er,.a.ai.aa„r**,kr*+14a.i.,.#*,r*w**a,.,.,.**h*,:,i.***,n*a.i.a.aw+r a„i„N...�*K*,r,r a.,.i.,c,h*:
<br /> SECTION 2 - To be filled out by tank removal contractor:
<br /> FTank Removal Contractor: -B&I M --vC--L1 s ly pt C-L b t✓a
<br /> Address: 3137 Sly V-A ��,_ Z° City: CAs-lyo Vazip: 8454 CO
<br /> Phone Y: ( 7 0 7 } 7-41 + 0 7 Date Tank Removed:
<br /> ----*_**. .............**------- ------*---*#......=.,K*
<br /> I SECTION 3 -To be filled out by contractor "decontaminating dank":
<br /> Tank Decontamination Contracmr: f,rv'I—V i c— VA 1)
<br /> Address: 3 o C e_� City: TM A n c k Zin: 531
<br /> FPhone #: ( 'Boa) 3Z-- 4(aq 5
<br /> Authorized representative of contractor certifyi.ag through siy azure below that the tank has been decontaminated in an approved
<br /> Fmanner as required by Cal EPA.
<br /> Name: Title: Signature: Date
<br /> { ........,....,i#,.
<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 ;`fame: :F-I/l C �S ol1
<br /> F. A,Idrc,,,,:
<br /> 2 5s �� �v �1 �! City: f�Mw,a N zip:Phone r: ( 510 ) 23 � - l 2✓�
<br /> FDate Tank Received:
<br /> Name: Title: Signature: Date'
<br /> EH 23 046 (Revised 10119198) Page 10
<br /> E
<br />
|