Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> e / voC. <br /> UNDERGROUND DISPOSITION TRACKING RECORD <br /> *********************************************************************************************************** <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: 6P IAPco # 602-0 <br /> FACILITY ADDRESS: 1nv e-ys,-j'Q a-h'-e-CA C 94-3 3 <br /> TANK ID#39- SIZE: a 3 (0,a- PREVIOUS CONTENTS: U h <br /> ,pc UQC.. <br /> SECTION 2-To be filled out b��•taak.removal contractor: <br /> ?,PC /uoc- <br /> Tnrk Removal Contractor: P A(I-A->0\S o F-C C <br /> Address: �-b O W l`�o-r`^S S+ City:50'r\ 94 S 4 <br /> 1f prpe v0[. R <br /> Phone#:( '5+0 ) � `1- '8310 Date emoved: T !J <br /> *********************************************************************************************************** <br /> SECTION 3-To be filled out by contractor"decontaminating to k": p;pe- / v r7 C_ <br /> P' c JOG <br /> r Q Decontamination Contractor: pT_ a l a e e-ck oSP-d as ti AL. <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 /> *********************************************************************************************************** <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting 4ank and/or piping. <br /> Facility Name: 05 1 / �j Q <br /> Address: P-0 C�)< 5 g City: Qe� VZip: D 1 003 <br /> Phone#:( _) TSn ee& 1 '0 11 NV 00Lf4a9yt016 <br /> Q�pe-/UjOC_ <br /> Date Tmrk Received: T <br /> C(" � • / <br /> Name: C <br /> V. <br /> . . r,l O✓0e—Tn <br /> itle: C(U�. (Ka'^O'f el Signature: = v Date (0—/0-08 <br /> ***************************************************************************** *************************** <br /> EH 23 046 (Revised 12/31/07) 10 <br />