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PUBLK] HEALTH SERT'ICES <br /> SANJ0AQL:1N COL ND' <br /> IOGi KHANNA QLD.M P I] <br /> Health Officer �. . <br /> P.O. Box 2009 • (1601 East Hazelton Avmue) • Stockton, Catdornia 95201 �cr°oaf <br /> (209) 4683400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 rrespons—i�b-le for ensuring that this form is completed and returned. <br /> FACILITY NAME: ( �CJ// �Mm t P �c+j'u d, f\ /n <br /> FACILITY ADDRESS: I ) So f{U/) bA <br /> TANK ID #39 - /993_ Z Tank Description: I l JF 0 - U a l �L ga Sol in P <br /> ............. ...............��.....................,.........................,......................... <br /> SECTION 2 - To.. be filled out by tank removal contractor: Fname I^ <br /> Tank Removal Contractor: <br /> Address: q //y� City: a j 1 Zip: <br /> Phone #: ( I6) �—�ow Date Tank Removed: <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank': (' n <br /> Tank Decontamination Contractor: <br /> Address: RES Parr Q�u city: zip: Seff � <br /> Phone #: f y IS ) a 3S 3R 3 <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 Department of Health Services. <br /> Signature: Title: <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. eo <br /> Facility Name: p I C SL1/1 <br /> Address: C� ���1 , rPQ(T P1V� City zip: OO <br /> Phone #: <br /> Date Tank Received: <br /> Signature: Title: <br /> Page 10 <br /> EH 23 D49 (Rev 2/8/91) .+p <br /> A 13n11-m n'San Ioaouln Cnunn Hr+IN Csc Scnim �7 <br />