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A. , jZL.CjLI i'j 04:Y Aat6 <br />• SAN JOAQUIN COUNTY <br />JOGI KHANNA M.D. M.P.H. <br />Health Oiler <br />P.O. BOX 2009 • (1601 Past Hazelton Avenue) 0 Stockton, caawrnla 95201 <br />(209) {68.3100 <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />SECTION 1 - Public Health Servlces Tracking Sheet will accompany each tank affixed with Its site Identification number. TLS <br />Tracking Sheer is be returned to le Health <br />facility- Tho Permit <br />Services wlthln J0an dof 9cceptance of the tank by the disposal or rcgclln <br />lt hotaer b responsible for easuring that this form Is completed and returned. <br />FACILITY NAME //f /?T <br />FACTI.I'IY <br />am <br />,5-T7?- <br />TANK <br />5T2 <br />TANK ID #39 . _� Sv - v I Tank Description X000 gAC GOv ��} SOL/,WJE <br />SECTION 2 - To be tilled out by tank rornoval coalfs4or <br />Tank Removal Contractor. S E/rJ GO <br />Address: 6t/, City P)MC-5(—o Zip. 953s/ <br />Phone #:Z( 05 1 SZ q 9'(p S3 <br />Data Tank Removed: <br />SECTION 3 - to be 9llcd out by coairactor'docontamhlaUng tank. <br />Tank DewataminaUOn Contractor, <br />Address: e�J. Mr. Zlp: 9S3S/ <br />Phone N: ( Z4`I t <br />Authorized represerequired <br />by the of State Uactor, certified by sigaing below that the tank has been deo0nlamhralad in an approved <br />manner u requlreA by the State Department of Huth Services, <br />Signature: <br />Me: <br />............................................................................................. •............. <br />SECTION 1 - To be signed and dated by an authorized rsepcsaentative of the treatment, storage, or disposal facwly <br />Faeitlry Names <br />accepting is" ander piplalg, <br />Address: `6L 412 -�/77<E�7T City: �l/Gy�y/D.v� 9513a <br />Phone #: (�/5- t ?36 �tini <br />s zip: <br />Date Tank Received: <br />Signature: <br />T111e• <br />Page 10 <br />EN 23 049 (Nov 2/anl) ttP <br />a nt.trv, ar r••)W" cw..r He•Wt rte sw.rn, 0 <br />