Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAID JOAQUIN COUNTY <br /> Telephone:(209)468-3420 Fax:(209)468-343.3 <br /> UNDIERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> swaeawwwwwwxwwwsewsw.rwww+.w+wiwwwwrwwrwrc:wewesv,cawinr.+twwReewswe+wwwwswwwwwea-+wwwswwwrxe _ <br /> SEC"nON 4 —.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.30ans dof <br /> acceptance of the tank by the disposal or recyckng facility. The penult holder Is responsible for ensuring that this form is completed <br /> and returned. <br /> FACILITY NAME: fij44FR L.i`SCS' pfAL-"n <br /> FACILITY ADDRESS: t„/ArfI4IAAfUAj 5 V 5tat*40N,rte, S'oto <br /> TANK ID#39 Wit' A.• TANK SfZE: ----S®0 G 40r-PREVIOUS TANK CONTENTS: <br /> ,���rsxx*arm*,�*�x•�**•,��*���*�*x�,����;�**�a**�����***,a.,r�**�,�***�x�r*,�*�*«**x�e*��**,+a*�*�r*�� �r��*+r***�*�,�**** <br /> SECTION 2-To be filed out by tank removal contractor: <br /> Tank Removal Contractor f P r <br /> 'No t zip:Address �j 3 Ty9 <br /> Phone#:( �4 t 1 1102— qfg Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank'; <br /> Tank Decontamination Contractor. h P f <br /> Address:_ )(df} T City:, zip: �13�f3f <br /> Phone#: G ;o 3 - <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 /> ,�**��ae*+�*trxarm**t,�te�t��*tr*x;���teis,ksrk,tea*�,t,�t�,ta�eate�vere�rt+�*mak*�,r*+ter:rtr�,ter*t�r�x+kteate*,tx,�*ter*�,t*,�* xs� <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: Thr Zip: <br /> Phone#:(__-� <br /> Date Tank Received: <br /> Name: 1"rtle: Slgnature:_ gate <br /> El{23.W (Revised 8/1/11) 9 <br />