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UIN <br /> PIJB'L�T HEALTH SE;�WICES 'O.p <br /> S,�NJOAQL IN an'Nn' <br /> 106i KHANNA M D.M P H <br /> Healy`Ofnor <br /> ( <br /> P.O. Box 2009 • 1601 East Hazelton Avenue) • stodzon, California 95201 't koit <br /> (209) 468 3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ..........................................................................<....<......<......<............. <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 eithin 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 NAI4E: ( �ranl to 1dIt7/\ <br /> FACILITY ADDRESS: <br /> 10C'm sodO/) A60d <br /> TANK ID #39 - I49'�' Tank Description: 1(_ roo -- U4r±l_IL ya So�tn P <br /> ..............................�e�. ....................................................................... <br /> SECTION 2 - To be filled out by tank removal contractor: a ice, <br /> Tank Removal Contractor: q�—Q'��7 <br /> f city: _ zip: _Lt�L1 L— <br /> Address: q / 1 <br /> Phone #: ( I�f1 ) Date Tank Removed: <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank": r n <br /> Tank Decontamination Contractor: <br /> Address: <br /> SES Pari �IU City: ��c.�vr,yn� zip: SD <br /> Phone #: <br /> Authorized re esehtative o contractor certified by signing below that the tank has been decontaminatede�ap�rUo��� <br /> manner as re it by th tate Department of Health Services. -,pr <br /> fie <br /> Title: <br /> signature: <br /> SECTION 4 - o be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. C S(� <br /> Facility Name: <br /> ' ash Parr <br /> Address: City: Zip: <br /> Phone #: 9 <br /> � 3 <br /> Y Date Tank R iv <br /> Title: <br /> Signature: / ilLir�^vi5 � <br /> ......<...<... ......<..........<.....«......<t...<......<.<...<......a....«..........<....<..<........ <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) wp <br /> A Dnision olS� Imquin Cnunn HOktI Cva Srniro �7 <br />