Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1-Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany eacli 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 bolder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANK ID#39- TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SECTIO, 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: ' <br /> Address: City: Zip: <br /> Phone#: ( ) Date Tank Removed: <br /> ��rt��«*•�*s*��*******x**xis**»******��*r�*s**�»**�**#��*»*�***�*��s:�*�****�****���:���*�***�**�**�***�***�� <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> i 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 /> 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: City• Zip: <br /> Phone#: ( ) <br /> I <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 08113/99) Page 10 <br /> I <br />