|
PUBLIC HEALTH SERVICES �o.�- WfNy C,o`
<br /> SAN JOAQUIN COC M : ,
<br /> JOGi KH.ANNA M.D..M P H
<br /> Health Officer
<br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201
<br /> (209) 4683400
<br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD
<br /> ...,......,•...................s♦r«u•uaaa,••••u,uuaus•suu•u,•uuuu•rruu•u,uusr rruruua,•
<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-iib-le for ensuring that this form is completed and returned.
<br /> FACILITY NAME: ( 9fQni tQ On n. IrrcUGf4,6,l f� ,Q
<br /> FACII,ITY ADDRESS: I O i(7m sok I kda,) 7\t
<br /> TANK ID #39 - 3's�CC Tank Description:
<br /> aauar•«ra••u,••sr,•rruus•,•`,Sr sra,••u••ara,u•r„,•....,.•......................•....,•....•........
<br /> SECTION 2 - To be filled out by tank removal contractor:
<br /> Tank Removal Contractor: C,,(n E (�
<br /> Address: / City: - i, =�— Zip'
<br /> qguy
<br /> /�/�
<br /> Phone #: L am_ 3RI—j ow Date Tank Removed:
<br /> •ausu,ssaussa a,r,arur«sr rssuasaa,ssu„rauusasuuar„rassu,,,suussa,rruuuusr•uu,aass••us•
<br /> SEMON 3 - to be filled out by contractor 'decontaminating tank":
<br /> Tank Decontamination Contractor:nDn
<br /> Address: g5s l a,, IIU City: Zip: UO
<br /> Phone #: Lia) a J"�— I SR 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 /> ar,rs•susu•rr•s•urusa as•aa,u,s•ssasra•suraarsr♦u,u„••ussaa,u,us u,•,rrr uruu••«........,..•..
<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.
<br /> Facility Name:
<br /> Address: 4�S- 7 irCif r 4710 CityZip: OO
<br /> Phone #: (
<br /> Date Tank Received:
<br /> Signature: Title:
<br /> ssuasuaa»•ruu•r••,ur,sss„sraa,sr•urs,•ssrra♦ruau,uruu uuu•uuu•us•tu s•u„•u,a•ua,as•
<br /> Page 10
<br /> EH 23 1149 (Rev 2/8/91) vp
<br /> A Division of San Joaquin Counn Health Care G-mcc 10
<br />
|