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PUBL1"C, HEALTH SERv ICES ,0�4 •`N CO` <br /> SAN JOAQUIN COUNTY ? <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 • (1601 Fist Hazelton Avenue) a Stockton, California 95201 <br /> (209)4683400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> r t t r r i i r r a r r r r r r>r>a r>♦>r i>r»>p»»>•r»r>»r»»>♦»>r»»»r>r r>r r»>+«r r»»>r>r>+«r r»»»»»»»a o <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: ?/ T/�f'c1L®C FTI�l��IL <br /> FACILITY ADDRESS: �8/�/ �/R-b A"'t u-r <br /> TANK ID #39 - Tank Description: t—to 00�? JZa�. 6AS <br /> r»r>«»»»>rs♦iririri»r•r+>rrrriririiiii>r+irr»»>w>>rir+rrirr>u»»»»>r>rriiiiiiriiii»»>r»»>r <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: sEm� v1 'n <br /> Address: 0/ GJ 1147-eN ,®DAD City: Alo 'o Zip: 9535/ <br /> Phone #: Zo 57,t 9653 Date Tank Removed: <br /> >t»♦>ttr troriri>1 t>rtiiititit>t«>riliti>sat»♦i>Nq>»t>ri>irrigiti♦it»r>tirit>>liitiiri ti>it>tiArrrt« <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: �;E/NGo <br /> Address: y3I (J fll77u/ 12,W) City: 4GDE5To Zip: 9535/ <br /> Phone #: 5'y <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 /> >r»rr rorrr»»>o«i«q»»ri«aa>rrr>rr>rr«r>»»»r»irrro»>or>rrrr>r>»r>r>«r»r>»»rr>rir»»>rrrrrr»»o <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: t tJ/'L 4C-5 t 4i2r00/LJI�OH <br /> Address: 600 `fes ST.zarr City: /ei;MOAID Zip: 9V,20/ <br /> Phone #: ( /15- ) 236- 042 0.6 <br /> Date Tank Received: <br /> Signature: Title: <br /> ♦roar>»tatrtor>r>oorrrurarr>rr>t«raar>ror»rottortro>rttartorrrrttrtt«rrr»>r tatoaor utttr>twott«traa>r <br /> Page 10 <br /> EN 23 049 (Rev 2/8/97) wp <br /> A Division of San Joaquin County HdN Care Services <br />