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PUBLIC HEALTH SERvICES <br /> SAN JOAQCIN COL i� 11 V <br /> JOG! (;HANNA M D. M.P H <br /> Hench.Officerr. <br /> P.O. Box 2009 • (1601 Ezst Hazelton Avenue) • Stockton, California 95201 �t,FoaN <br /> (209) 466-3400 <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 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: ( 9/frani i P \Cc,Q(_.�c��r l c4J&Nl nn <br /> FACILITY ADDRESS: I n�� U� flan bA <br /> TANK ID #39 - 113- 3 Tank Description: It7 OOTA�� <br /> SECTION 2 - To be filled out by tank removal contractor: h E in <br /> Tank Removal Contractor: �� 41 <br /> Address: p ul Ci - — �P <br /> Phone #: , yD I-� t�W Date Tani Removed: <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank': r n <br /> Tank Decontamination Contractor: k�o Ay Q <br /> Address: �1R55 PLIfC I�IU City 1( u Trp: too <br /> Phone #: c -715 1 ; 3 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. do <br /> Facility Name: t— p C Sd/1 <br /> Address: l�a�J ' rPQrr PCity tn() 7-p: gel <br /> Phone #: ( <br /> Date Tank Received: <br /> Signature: Title: <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) wp <br /> A Dni+iun n'San it q, iM Cnu11 MoIlh Cme 411cc 7 <br />