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PUBL-rC HEALTH SEir710ES ,0'0UIN,.CI
<br /> SAN JOAQCINCOCNTY „ Z
<br /> JOGiAHANNAM1).MPil r .l <
<br /> Hralth Officer c �:•
<br /> P.O. Box 2009 • (1601 East Hazclton Avenue) • Stockton, California 95201
<br /> (209) 4683400
<br /> UNDERGROUND TANK DISPOSMON TRACKING RECORD
<br /> ,,,,,,,,,010
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<br /> SECTION 1 -Public Health Sendccs 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 dans 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: �/rrant tP 00fi.& � 6A
<br /> FACILITY ADDRESS: (J I m f
<br /> so I t u m) A60 p
<br /> TANK ID #39 - - Tank Description: 20 to t) - SP
<br /> SECTION 2 - To be filled out by tank removal contractor:
<br /> Tank Removal Contractor:
<br /> Address: City: mar Zip:
<br /> qS
<br /> Phone #: ( I�fi ) c�OI—I6(�lJ Date Tank Removed:
<br /> ' SECTION 3 - to be filled out by contractor 'decontaminating tank':
<br /> Tank Decontamination Contractor: n
<br /> Address: REs- rAfc 1�'U City: .gkdAgdjj Zip: go
<br /> Phone #: ( '%'S7 ) a 3�- I �R 3
<br /> Authorized r r ntative of contractor certified by signing below that the tank has been decontaminated in an a7roved
<br /> manner as equir by the rtate Department of Health Services. C�
<br /> Sign atur : Title: -`_if'-ro'YsCr 1_ '41 t✓/ r�/\
<br /> SECTION 4� To be signed and dated by an authorized representative of the treatment storage, or disposal facility
<br /> 666666 accepting tank and/or piping.
<br /> Facility Name: ^^ (J Q p
<br /> Address: /1 oC��, P6cf• t�1I 0d City Wv Zip: q 90
<br /> Phone #:
<br /> Date Tank 7 ��
<br /> Signature: R iv Title: Ra.'VI-xi -
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<br /> Page 10
<br /> EH 23 049 (Rev /8/97) vp
<br /> A Dnislun of San Jmquin Cmnn Mc Ith care Scni 7
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