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SAN JO. JIN COUNTY PUBLIC HEALTH SERVI, <br /> I; IRONENT,�L HEALTH DIVISION <br /> UNDERGROL-iD DIORAGE TA,N=; DISPOSITION i-R%CKIN,.AECORD <br /> ...e.a...........rr.....a.r...wr....awa.rrr..wr.aw.........**.........srw......a................rr....rar.. <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affued with <br /> ,¢ site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Envirotunental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> his form is completed and resumed. <br /> FACILITY NAME: A. Teichert & Son, Inc . <br /> %CILITY ADDRESS: 103 North E Street Stockton, CA 95205 <br /> TANK ID .i39 - 155-5-6 TANK SIZE: 20 , 000 _PREVIOUS TANK CJNTENTS: Diesel <br /> ....s..s.........es..s..r...rwr........s.s..r....rr......a.....rww...........s............-..rwsssr.w..rrr.. <br /> SECTION ? - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Town & Country <br /> address: 3373 Luyung Drive City: Rancho Zip: 95742 <br /> Cordova <br /> ?hone p: ( 916 ) 636-9500 Date Tank Removed: March 23 r 1999 <br /> .......................sr..........r.rrrr.................r..................s.r---------........ww........ <br /> SECTION 3 To be filled out by contractor "decontaminating tank": <br /> -ank Decontamination Contractor: Philip Services Corp. <br /> address: 395 West Channel Road City: Benicia Zip: 94510 <br /> ?hone #: ( 707 ) 746-8287 <br /> authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> :Wanner as required by11Cad EPA. 1/ <br /> Name:�oJ:o �tG� (J• LEnTitle: V tomQ'I A4StpEwiT Signature: Date <br /> ..a.aw.awa.r..rr..rr....ssrrr.rr.rrsa.r.rs..ssw..w.sr:arawrr.w.sr..r...........rrasr..sssrsr.rrrwr.w.rsr.s <br /> SFCTION 4 - Tn be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting ank and/or piping. <br /> Facility Name: Triangle Inc. Of Sacramento <br /> Address: 3525 52nd Avenue City: Sacramento Zip: 95823 <br /> Phoae #: ( 916 ) 421-1990 <br /> Dam Tank Received: March 23 1999 <br /> Name:Nick Chronis Title: President Signature �H ace 3 2-3 <br /> .....s.......a............♦....srs.rswsrs.sr.aus...s.....rs.r..............s....r............*.......... <br /> FH 23 046 (Revised 10/19/98) Page 10 <br />