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PUBUt HEALTH SERv ICES SAN JOAQUNCOI'NT)' N Lt TOG; KHAN NA M R.UP ii HralthDiiicer • c�i;� P.O. lox 2009 0 (1601 East Hazelton Avenue) 0 Stockton, California 95201 FO0 (209) 4683400 UNDERGROUND TANK DISPOSITION TRACKING RECORD ........................................................................................................... SECTION 1 -Public Health Sen�ces Tracking Sheet sill accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: nn�rat�P Crl sicudwn n FACILITY ADDRESS: 1 n 7 U W�n OGII�1 11 TANK ID #39 - qr�3- Tank Description: .......... . .......� .1 ..............,.....................,.,.........,..................... SECTTON 2...- To...be...filled....out. by tank*removal contractor: Tank Removal Contractor: Address: �-C2 �l City: Trp: � E .3 Phone #: ( � 38/-1 Date Tank Removed: SECTION 3 - to be filled out by contractor 'decontaminating tank": Tank Decontamination Contractor: n Address: �1R5S parr IJIU City & Qu Zip: MO Phone #: ( if�� )-2 3� I M 3 Authorized representative of contractor certified by signing below that the tank has been decontaminated in an approved manner as required by the State Department of Health Services. Signature: Title: SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility Facility Name: accepting tank and/or piping. (J p I C ,SL1/1 Address: �� T Circ PJuj City Trp: �d� Phone #: Date Tank Received: Signature: Title: Page 10 EH 23 049 (Rev 2/8/91) up ^, A Dh11...n rtSar.Joaquin Counn H,1t C.,Fnim C /