Laserfiche WebLink
JOAQUIN COUNTYHEALTH <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACIGNG RECORD <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br />Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME <br />FACILITY ADDRESS: 44-00 <br />TANK ID #39 - TANK SIZE: 10 ems% PREVIOUS TANK CONTENTS: UtJ <br />SECTION 2 - To be filled out �by tank removal contractor: W <br />Tank Removal Contractor: e t.V r & f st:)i> GotA;T&VC� ®9 <br />Address: '170 0-07s t ' City: l Zip: <br />Phone #: (1-01 S t-7 " 3, 10 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: <br />Phone #: (_� <br />City: Zip: <br />16%rm <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: 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 <br />Phone #: ( ) <br />Date Tank Received: <br />Name: <br />Title: <br />City:_ <br />Signature: <br />EH 23 046 (Revised 9/11/96) Page 10 <br />Zip: <br />Date <br />