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PUBLM" HEALTH SERilCES <br /> SAN JOAQUIN COUNTY ?, <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton,California 95201 0,i i ii 614, <br /> (209)468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> •rrraarr»•trrrtrtatrttatattattatttrrrarprrsrawaaaaa»ataaaaaaataaattrtrrstrrarrataaaaaaaas»satatttarrrr <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: ?/ TA�ILg�C F�i2T/u��lL <br /> FACILITY ADDRESS: /8/q df4oAlt 6c7 <br /> TANK ID #39 - Tank Description: _ l-t o ono of Bb e e— <br /> •rrrrtaarrrtrrrtastpgatasa»aaapaaaaarararaasaaaaaaaasatrraaaaaaarraaataaraaaaasasraartarrrrarrrrarrrr• <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Simco <br /> Address: VW dJ f/9Tu/ AWD City: A10-F-Vo Zip: 9535/ <br /> Phone #: Zo 577 9&53 Date Tank Removed: <br /> •rraarasr rararrttrttrrtpaawtt»tssataasaaaataaaaaaaaaartaa»aaarsraaassaaasaararaaaatsasrrratatrtarrrrrta• <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: �;elnc-o <br /> Address: �/3/ y f��9Ter/ inn City: �PGOF.STO Zip: 9535/ <br /> Phone #: (205 ) 52 y4 q105$ <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 /> arsarrtrarasrrraaurarraraarrasaatrtrararaarrararraaasrasaaatsaartararasaaraaatara»aaaaaaatatatasaaaasassa <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: �tl/ti /�E7/�GS CDi//Q�y/LrtsoN <br /> Address: 600 �{� Serra E City:/T/U;XOA-D Zip: 9Yyo/ <br /> Phone #: ( /!5- ) 236- 060.6 <br /> Date Tank Received: <br /> Signature: Title: <br /> •rrrrrarrrr»arsrtarasaraaarasaaaaararatarsaarsrta tr tr»saaataaarassrrarratarasra»»srrrrrts»rsrar rrrar• <br /> Page 10 <br /> EX 23 049 (Rev 2/8/91) up <br /> A Division of San lmquin CountyHc2ith Carr Serrica <br />