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PUBLIC* HEALTH SEP4ICES <br />SAN JOAQUIN COUNTY <br />JOGI KHANNA M.D. M.P.H. <br />Health Officer <br />P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton. Callfonda 95201 <br />(209) 468-3400 <br />UNDERGROUND TANK DISPOSMON TRACKING RECORD <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The <br />Tracking Sheet is to be returned to Public Health Services within 30 dere of acceptance of the tank by the disposal or recycling <br />facility. The permit holder its responsible for ensuring that this form is completed and returned <br />FACILITY NAME <br />FACILITY ADDRESS: 3 ZO SQ I7H 577�.eZo ✓ �7 / DONS C� <br />TANK ID #39 - I'a � 1 - d 2 Tank Description: <br />6, C�tVO 0-tcc6,U <br />SECTION 2 - To be filled out by tank removal contractor. sE/✓ICO <br />Tank Removal Contractor. <br />Address: 413/ 461, A17GJ/ 4�'O)9P City. <br />Phone #: 9�-X 965-3 Date Tank Removed: <br />/yI0.0 ESQ <br />SECTION 3 - to be filled out by contractor 'decontaminating tank': S � cc <br />Decontamination Contractor. <br />Zip: 9s3 sy <br />Address: �3( GJ N?7Gef .QOfiD City: /;�,EsZa tip: 9s3sy <br />Phone #: <br />Authorized representative of contractor certified by signing below that the tank has been decontaminated In an approved <br />manner as required by the State Department of Health Services. <br />Signature: <br />Title: <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 #: ( (s) �o d� 5Z6 <br />Date Tank Received: <br />Signature: <br />G -7/c <br />City: <br />��l�nati� <br />Mile: <br />Zip: <br />9`F 30/ <br />•••••••••••••••••►•••••a••••••►•►a♦•••••a••••►►a•a•••a•a•••••a•►•♦►••►••a••r•a••••aa•••a••a•a•aaa••••••••• <br />Page 10 <br />EH 23 049 (Rev 2/8/91) rp <br />A DKI m of San Ja•9am Cir HNLh Ca Senke• 0 <br />