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SAN WAQUIN COUNTY PUBLIC HEALTH SEAOCES <br /> ENVIRONMENTAL HEALTH DMSION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ...............+....r•....rrr........wwwwYwi+.r..irrrirrr•.r.rtr+.Yi+rwrr.irir+►•rr.....+•+riir.rrwrYr+Y•Y►r <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental 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 /> this form is completed and returned. <br /> FACILITY NAME: F0WLER'S <br /> FACILITY ADDRESS: 405 N EDISON STREET, <br /> -,SSSTTOCKTON CALIFORNIA 95203 <br /> TANK ID #39 - LTANK SIZE: U PREVIOUS TANK CONTENTS: yR ' t-j-+ t <br /> ...•...........+•+r••r+i++.r+rr+rr+rr+rr+rr+rurrr►r►r+r►rr+wirrrrwrr+rr..+►rrrrrrrrwrrrrrr+rrrrrr+rw►rrrri <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> JAMES J. HOBLITZELL <br /> Tank Removal Contractor: <br /> Address: BOX 30331 City: STOCKTON,CA Zip: 95213-0331 <br /> phone d: ( 209 ) 943 7793 Date Tank Removed: <br /> ..r..........+...i++i►•r•rrr++..rarrrrirr+rtwrtr.►++i+ri►.ir•rrrYY•+ir+Yr+•r+rrr+r►r+rr+Yrrrrr+r+rrr+•Y.+wi++ <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SAFE AS SECTION 2 DIRECTLY ABOVE <br /> Address: Ciry: Zip: <br /> Phone N: <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner ' <br /> Name: Title: Sigttatttre: Date tD Lp+z7 <br /> ..•r.rw+.rrr...+i.+rrr+r++rrrrisrrrri+►+•r++ri►rr+iirrr4rr+rrr++r►rr+rr•rr+r++t rr►•+tart+►Y+►rrrrr++•►r <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: WEST COAST EOUIPMENT <br /> Address: BOX 2368 City:TURLOCK,CA Zip: y53Rt <br /> Phone p: ( 209 ) 668 9378 <br /> Date Tank Received: L�t/ <br /> Name: Ot)1 j AMIETiile: Signa Date <br /> ...+.w..........r.r.Y+•+Ywr•rr+r+i•rii+rrY.iwrrir►rrr•rrw+►rr rrrrrwrr++tartar+++•+rrrrr+r++orrwro.• <br /> EH 23 046 (Revised 10/19/98) Page l0 <br />