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PUP, :IC HEALTH S' VICES
<br /> SAN JOAQUIN COUNTY
<br /> r.
<br /> JOGI KHANNA M.D.,M.P.H.
<br /> Healrh Officer
<br /> P.O. Box 2009 a (1601 Fast Hazelton Avrnuc) r Siociaon, California 95201 ti toPN
<br /> (209) 4683400
<br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD
<br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. "
<br /> Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recyc.
<br /> facility. The permit holder is responsible for ensuring that this form is completed and returned.
<br /> FACILITY NAME: C%?/ TN40..0 Ftzz-lugg1r.
<br /> ITY
<br /> FACILADDRESS: /g/,? A4o yt wr
<br /> TANK ID #39 - �2OaO - 0 3 Tank. Description: _ l-to,ora�Dees
<br /> SECTION 2 - To be filled out by tank removal contractor:
<br /> Tank Removal Contractor:
<br /> Address: VW 1,,) /197e4l k44D City: Zip: QS35/
<br /> Phone #: 20 5701 9(053 Date Tank Removed: /O -/7 -121
<br /> SECTION 3 - to be filled out by contractor 'decontamirtating tank':
<br /> Tank Decontamination Contractor: ';'; o
<br /> Address: 4,13/ U f1,y7Cel /loan City: ,6 earn zip: 95-3sL
<br /> Phone #: (205 ) SZ qG 53
<br /> Authorized representative of contractor certified by signing below that the tank has been decontaminated in an approve
<br /> manner as required/by the State Department of Health Services. p
<br /> Signature:l1;Kb11�/ ��li� Title: G�
<br /> •,,,,,••„rr,,,,•,,,•,,,p•• •,•,•0,•••,•„••,•,•,,,,•,[„t,r,r,,,,,•it,•3•,1Y„•,,,,LtiC!G[,[•44i»:...
<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: Z 1)16746S �flr0o/Lr't<oN
<br /> Address: S-r,zEe-r City: /";M0A,-P Zip: QuYO/
<br /> Phone #: �� ) 236- O 0.6
<br /> Date Tank R iv : D /
<br /> Signature: A Title: L
<br /> Page 10
<br /> E8 23 049 (Rev 2/8/91) up
<br /> A n1YL4Wf1 nr San Joaquin County Nd�h Gre San[:es � _
<br /> y/jf/ .TV�iGI/.Iil-O• - �/4 C^i.91��-/
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