Laserfiche WebLink
Envi onnTS-AN JOAQUIN <br /> _ OUNTY___ <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKIN k kDIIEN TAL HEALJT-;' <br /> FNT <br /> SECTION 9 -SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its <br /> site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 <br /> days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this <br /> form is completed and returned. <br /> FACLNAMIE`TM l d a" l l ` XY//FACILITY <br /> ADDRESS: 3 C t r--1 <br /> TANK ID#;SOI 0Y O0 2---TANK SIZE: 1�_PREVIOUS TANK ®Z- <br /> CONTENTS:W et41)X Q 1Z�Gt/L�i2 Gs�S®Z/s✓� <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: :T1/11 //-11V <br /> Address: 3 o 3 O City: zip:2- 0 <br /> �7 a2 <br /> Phone* (ZO _,�� Date Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontaminating tank":fi,40?1fi/v G/ <br /> Tank Decontamination Contractor: / 11p�I�,� <br /> Address:T� 4J � 3 S City: E--C/G� Zip: 5✓?i'�� <br /> Phone#: <br /> Authorized representative of contractor certifying through signature below that the tan as b en de ntaminated in an <br /> approved manner as required by Cal EPA. /5/9Zi4�2A p0 S <br /> ��//j�C:_ZC Si nature: Date���Z VL f2 <br /> Name:/�/9/2//,v %�1�� Title: w g <br /> SECTION 4-To be signed and dated by an authorized representativ f the tr atmen ,stor ge,or disposal facility <br /> accepting tank and/or piping. <br /> Facil <br /> Name: <br /> Address: (� ✓ Zip: 9, 7 �O <br /> Phone <br /> Date Tank Received: _ T <br /> Name: ��+// <br /> /�jtgs/� Title: ��. f�/� Signature: Date, -1 <br /> 6 <br /> , 0" /a <br />