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PUBLIC; HEALTH SERVICES qp <br /> SAN JOAQUIN COUNTYJOG[KHANNA M.D.,bLP.H. <br /> Health Officer <br /> P.O. Box 2009 w (1601 East Hazelton Avenue) } Stockton,California 95201 <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> •»ars#♦rs}ta saassasssssaa}•aaaaaa»Ras»}#a»++++++»ra}rwwr+:craws»a}�ata::trs•+a:»aaass Ra•+wr+trrrrt}rrrr} <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: .�ZGy�t!57 G-451, <br /> FACILITY ADDRESS: <br /> TANK ID #39 - 2553-01 Tank Description: ✓�� 5���©/y � 7�/�/S'.�� �//1 sSOL�/Yf'i <br /> +#+>w+Rwswawaaa•sswwtat}rrsat}tttar:wstsssaswss}swwtii}}s}wrtrsaaa}:ssassaa:sssi Yasass•Rw•wt•+# <br /> SECTION 2 - To be filled out by tan��rff��oval contractor: <br /> Tank Removal Contractor: 27 ZMVZ77 <br /> Address: �'�/ Gc p/f0.7lc�L' City: /+ Zip: <br /> Phone #: Date Tank Removed: <br /> :s RrR iRsww}i}}trsrs}i#+#+R•RY+•#a Rrww•Ri:iRaaaaaR•aaaRaaattaaaaa:aRR•+aRw#Yasw ss+iws♦»rr#+}»as}}}:sat <br /> SECTION 3 -to be filled out by contractor "dScSSntaminating tank": <br /> Tank Decontamination Contractor: L✓Eyy� <br /> Address: S y7 City: Zap: 9 000* <br /> Phone #: ia"9I <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 Departmen f Health Services. <br /> Signature: Title: <br /> uN+#Y## tawtRiiY YtatH•#Raa N+ wattairatwtwi»»af iiw HirtatR of#iitYtwi#tw#Yrrr}tr}ww}}}tHaia <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> Facility Name: <br /> accepting tank and/or piping. �"� <br /> LtCiy� �,� <br /> Address: �/sy"0 /A}�(J,y/ ���yE'/ City: Zip: 9 Cp7a5 <br /> Phone #: <br /> Date Tank Received: <br /> Signature: Title: <br /> t#a#ti#RR#ti}iiat}s»ttR}trlraf aRTRRwitalatiRtatattaa Rai!}aitit}ti!}}at}ttallttii}titt}tl titttai tt}Hritt#a <br /> Page 10 <br /> EM 23 049 (Rev 2/8/91) up <br /> A Division of San Joaquin County Health Care Services <br />