REMOVAL REMOVAL 1991 - Laserfiche WebLink

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PIJTp ..IC HEALTH S"NICES �,q.9A� SAN JOAQUIN COUNTY ? JOGI KHANNA M.D.,M.P.H. y` Health Officer P.O. Bos 2009 a (1601 Fast Hazdton Avenue) •Stockton,California 95201 (209)468.3400 UNDERGROUND TANK DISPOSITION TRACKING RECORD SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. T Tracking Sheet is to be returned to Public Health Services within 30 dues of acceptance of the tank by the disposal or regch: facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: TPW,04 F&C'TI u i�-e/t• FACILITY ADDRESS: �gl q kuo of u-r TANK ID #34 - ,7n>.?0 - O.Z Tack Description: R E% CRS- SECTION 2 - To be filled out by tank removal contractor: sEmeo Tank Removal Contractor: of Address: �F34 lJ f�9TU/ A&#D City: /0117'Wo Zip: Phone #: 209 51K 94,53 '4Date Tank Removed: 7- SECTION 3 - to be filled out by contractor 'decontaminating taak': Tank Decontamination Contractor: S'emco Address: 2/3/ 0 f✓'l97er/ Rorty City: 40-d65To zip: 953s/ Phone #: (2406 ) 52 y< 96 53 Authorized representative of contractor certified by signing below that the tank has been decontaminated in an approved manner as required by the State Department of Health Services. Signature:/ �Ii�fih Title: r♦r„•,r••••a♦„•,r••••♦u♦♦•,•,r♦••:a♦•,•r♦►♦•r♦.••,•••♦r..♦,•••••••••••♦♦••r,,,rs,♦♦♦♦♦♦r,rs rr♦•♦r♦♦♦r••. SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Z Facility Name: �tJiN /�E74LS c p�Q>do/Ltl<ON Address: 600 5/f7 S-r� City:// Zip: 9f<�o/ Phone #: ( 1!5r I 2'36. 060.6 Date Tank Received: Signature: Title: •„r♦,r•••••♦♦•, •• • ♦r♦ra,•♦r•♦ ♦ •,••♦p„r,•p•••♦•s♦♦•,••••••••♦•♦♦♦„rrl,rr,,,•♦♦♦,♦N♦r,♦,,,••a• Page 10 EN 23 049 (Rev 2/8/91) ap A nh uan o1$w Joaquin Cam"Heald C r Service . Shu .TiRvu,.>, ca. geu. suRve�y