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PUBLIC HEALTH SERVICES ,o.4U%Ni CO` <br /> SAN JOAQUIN COUNTY ? <br /> JOGI KHANNA M.D.,M.P.H. <br /> Healch Officer <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) •Stockton, California 95201 q l iio it <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> s;tt tsutr#tp;trllitirf rriiiif strsis;;i;»is;;;t;;r;slttllltlri»rrtsissllt!»!»ffllsrrrr»sirttfstttttl♦ <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 days of acceptance of the tank by the disposal or recycling <br /> facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: CJDt9?/ TAclLO� F�i2T/rl��� <br /> FACILITY ADDRESS: �8/�I A4o yt 6t-r <br /> TANK ID #39 - Tank Description: 5Qo UC <br /> Yitiittii;;;til Viif i;YtitrtYiiiitii;;i;iMiii}Yr♦Vitt Yiti4tii;irii Yitti Yiiititi;;iitrrtYYtrsit;i;tgttttii <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SE/y1ce? <br /> Address: 4!3/ GJ f/ATGN lP'00 City: A1M-e5?o Zip: 9535/ <br /> Phone #: 20 $-Zfh 9&53 Date Tank Removed: <br /> viii;sft;;ltYYiYsit;ss#}tititiit;tifftiii;i;t;;;f YYYtf;;;;titiriiiiit#tai#;lis Yris;s;;tatttrits;t#t;;tt tt it <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: l��inGo <br /> Address: y 114.74t/ /2Atp City: SPG-eESTo Zip: 9535/ <br /> Phone #: (2-05 ) 52 l 9(v53 <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: Title: <br /> i;tttt Yii4;i!<ftitt4#ttfiitttirrii;lgYirisii;i;ttitftViY!lilitii4ttrrtt YYrsiil;t YYittttlli Yff;irbiirli;ti <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. n_ <br /> Facility Name: z ltViti wt-74&5 tAi4r�0/1��oN <br /> Address: 600 eM? STJLEr, City: 1e4;X0A/-D Zip: <br /> Phone #: ( ) 236- 06 06 <br /> Date Tank Received: <br /> Signature: Title: <br /> ittttitrirtitiriitt tiiirt#itiit;;ittitt;tltiiiY#;ttR ii YY#iiiiiY##lift#ittrti illi#tiri##t;iirii#iiirit#ilii <br /> Page 10 <br /> ER 23 049 (Rev 2/8/91) wp <br /> A Division of San Joaquin Counry ficalth Care Services �� <br />