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` PUBLIC HEALTH SERVICES ,0'C;.F` <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> Heahh Ofli(er <br /> P.O. Boz 2009 • (1601 Eut Huelton Avenue) • Stockton,CallfDnda 95201 <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SECTION I L Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The <br /> Tracking Sheet R to be returned to Public Ilealth 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 /> Fn.QLITY NAME: 1 ."haa ,e <br /> FACILITY ADDRESS: ��� �/a P P L�/n\I <br /> TANK ID #39 - I&I Tank Description: u)or) P A&) <br /> SECTION 2 - To be filled out 4,tank remo al contractor* <br /> Tank Removal (Contractor: <br /> _I". <br /> Address: o . Rn k City: ALt�2fdL1A— Zip: X9302 7 7 <br /> Phone #: ( ) q,3 L:/68 Date Tank Removed: <br /> SECTION 3 - to be filled out by contract�y "decontami1�acing rappk': <br /> Tank Decontamination Contractor: ( '_RICH ( ' "11 11) I <br /> Address: _r.D , Rix �Uat`n City: Lsn Zip: _C/.3Q77 <br /> Phone #: <br /> Authorized representative of contractor certified by signing below that the tank has been decontaminated In an approved <br /> manner as required b he State Department of Health Services. <br /> 0 <br /> Signature: IDZ ez�2- 1E1 Title: f <br /> •••.•••••••u••••••••••••••••••••••••••••• •••.•••••••••••••r•••u••••••••••••••.0•••••••••••••••••••••••• <br /> SECTION 4 -To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepJJ��ng tank and/6r pip'n . <br /> Facility Name:_ ( '(a (lA 1Y n111f <br /> Address: j,�1��, �111xalOn(( lr� <br /> City:�� Zip: �, yt) <br /> Phone #: (lLb 6 g— 1137W <br /> Date Tank Received: <br /> Signature: <br /> Title: <br /> Page 10 <br /> EN 23 049 (Rev 218191) "p <br /> A DIAS[..of San Inamdn Cnunry 11­1,h c........a... Ir'' <br />