Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*********************************************************************************************************** <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. I �)E F E j )GC f-')15 j vi i em —,'[W Dt PC `j" <br />FACILITYNAME: beFeQsF ( S►CS 146CO% '56Q _ 1)AGUlk) SAAP-PE 5,-rC <br />FACILITY ADDRESS: <br />TANK ID #39 - % g/cf�TANK SIZE:J2 PREVIOUS TANK CONTENTS: /�f5 <br />*********************************************************************************************************** <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: f� S �,�I�//l,/ 7�� % S1iC. b City:Sgeeig mer ! C.; Zip: qs �--S <br />Phone #: (_g&_) 6D l — ,JC) el Date Tank Removed: <br />*********************************************************************************************************** <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address <br />Phone #: ( ) <br />City: <br />Zip: <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: <br />Signature: <br />Date <br />*********************************************************************************************************** <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: <br />Address: <br />Phone #: ( ) <br />Date Tank Received: <br />Name: Title: <br />City: <br />Signature: <br />Zip: <br />Date <br />********************************************************************************************************* <br />EH 23 046 (Revised 08/13/99) Page 10 <br />