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PUBUC; HEALTH SERVICES <br /> SAN JOAQUIN COL NTY <br /> JOG! KHANNA SLD_ MP H <br /> Health O6irer c . <br /> 4t <br /> P.O. Box 2009 (1601 Ea_ct Hazclton Avenue) 8 Stockton, California 95201 <br /> /FOp~ <br /> (209) 4683400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 -Public Health Sen�ces 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: �/f�a�n-t�ty2n. t UC�IdnI <br /> FACILITY ADDRESS: 1 U : (� 'so tion OJ <br /> TANK ID #39 - 3-11 Tank Description: <br /> SECTION 2 - To be filled out by tank removal contractor: A. E In <br /> Tank Removal Contractor: <br /> Address: City: �_ tip: 7 J DoCd <br /> Phone #: ( I�A ) y0I—� 6C� 1 Date Tank Removed: <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank': r n <br /> Tank Decontamination Contractor: <br /> Address: 25s- Pac'c 2�h City:,..-s(n�c,r�� tip 9 <br /> Phone #: <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 /> Facility Name: <br /> accepting tank and/or piping. <br /> p <br /> Address: a��' rPCiCr P10� City h>V Trp: OQ <br /> Phone #: �Q3 <br /> Date Tank Received: <br /> Signature: Title: <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) wp <br /> A Dn11-1 n'San)0m -n Cl-n' Hll1 Circ'mire• �7 <br />