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PUBLICOHEALTH SER&CES <br />SAN JOAQUIN COUNTY <br />JOGI KHANNA &I.D.. M.P.H. <br />Hesith Officer <br />P.O. liar 2009 • (1601 East Hazelton Avenue) • Stoclaon. C>lifbrnU 95201 <br />(209) 468.3400 <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />.•...•••..•....••.u•••••••a1•uu•••••u•u•••u••••u••••••uu•••••••••••►a•••••a•au•a•a4►•a•aaa•••u• <br />SECTTON 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 days 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: 1 1,zqdN /01/LG/il/6 <br />FACILITY ADDRESS: 3 ZO Sc, r?H S?D�.rTa ✓/�GN� CfI <br />TANK ID X39 - I L/ S I —n 1 Tank Description: 101000 644-,- srtl <br />......................................••.•..•..a..•.•a•..a•........•..•.a.....••..•....••.a••aa•••.•...•.. <br />SECTION 2 - To be filled out by tank removal contractor. SE�Ieo <br />Tank Removal Contractor. <br />Address: 413/ 4(1, A%177Gd 1�eVW City: OOEStb Zip: <br />Phone #: 5�w 965-3 Date Tank Removed: <br />..a...•.•....•..a••.•.•.a.•a•aaa.•..•a•a•••••as.a.•.a•...aa•••••.a.••••a•aaa►0 a 00000080•60•0000 a.•••.••••.• <br />SECTION 3 - to be filled out by contractor 'decontaminating tank': E CS <br />Tank Decontamination Contractor. <br />Address: � 3 � w H77e f Qofto qty: �'1oy�za yip: F!5 51 <br />Phone #: ( '-f% <br />SL4� `16 S3 <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 Service. <br />Signature: <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 />ST, <br />Phone ;it:T( (sl 2-S�o d6 5.6 <br />Date Tank Received: <br />Signature: <br />G�c <br />City: <br />Title: <br />M <br />9 3,V/ <br />•a••••.••.•••••a••••••►••a••••••a•a••••••••♦•a•a►••••••••••••••••a•••p►a1•a••a•••uaa•a••aa►►►u►ua•ar• <br />Page 10 <br />EN 23 049 (Rev 2/8/91) Wp <br />A DhMkn of Ln JogWn Camr Hc• th Cye Ser"m \l <br />