Laserfiche WebLink
SANJOAQUIN Environmental Health Department <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> *********************************************************************************************************** <br /> SECTION 1 — 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 /> FACILITY <br /> FACILITY ti G � 0 <br /> ADDRESS : fJ (,,(/ ; [ <br /> r <br /> TANK ID #39 - TANK SIZE : 5 a PREVIOUS TANK <br /> CONTENTS : rirel/CAAQ41A�l �f'L. <br /> ******************************************************************************************************** <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: �2(�� lG //V (f / <br /> Address : �D ® '� ®�� City: L Zip: e741 <br /> Phone #: Date Tank Removed . <br /> SECTION 3 - To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination Contractor: / � �i�12 /�� ©�L /✓V <br /> Address : l' x , 3 57 City: Zed � Zip : D2 �7 1 <br /> Phone #: <=-�� ' 3 ` o, <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as required ly Cal EPA. <br /> Name : NAetrl'j /W�/�j�/9.- TitleC4A) 7'1 Cl /t3ignature: Date <br /> ******************************************************************************************************** <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 /> NameY �V � ) ---S.�ig5 f ��a V � �� / / �f✓ <br /> Address : 7i ®l///7 1pc f/ City: I/IE41 10r, Zip : �f 7 � g <br /> Phone <br /> Lu- ct) <br /> ! ,g n q� <br /> / 0 <br /> Date Tank Received : <br /> Name : Title : Signature : Date <br /> 9of10 <br />