Laserfiche WebLink
0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 completed <br />and returned. <br />FACILITY NAME: W16 Oh N Y1,v <br />FACILITY ADDRESS: IcluI �, L Dc'6(tk, J , <br />TANK ID #39 - <br />TANK SIZE: PREVIOUS TANK CONTE <br />******************************************************************************************************** <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Phone #: <br />Date Tank <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Phone #: ( N - I) /[ 1 Id- b ) J—� <br />City: Zip: <br />5 <br />City:l�1 1�(. /( ._Zip: <br />Authorized representative of contractor certifying through signature below tante "' ' bTT2T"ated in an approved <br />manner as required by Cal EPA. <br />Name: 1J1n 1Title: __.._._..._.. ... l / <br />L %,��" '� Signature: Date a 1 — f 7,_ <br />SECTION 4 - To be signed and dated by an authorized repr ntative 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 />City: Zip: <br />Name: ( Title: Signature: Date <br />EH 23 046 (Revised 07/22/10) 9 <br />