|
PUBLIC; HEALTH SERVICES ,ot� �a�
<br /> SANjOAQ(IiNCUCNTF =` .
<br /> I� _1
<br /> JOGi nH,�NNA M.D.UP li Ni, A.
<br /> healm Ot^cer epi'
<br /> 9
<br /> P.O. Box 2009 0 (IGOI Eur Hazelton Avenue) 0 Stockton. California 97201 cO
<br /> << *P~
<br /> (209) 468-3400
<br /> UNDERGROUND D TANK DISPOSITION TRACKING RECORD
<br /> .........................................................r.............,....,,.,..........,,r.,...,,.......
<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: San Joaquin County Courthouse
<br /> FACILITY ADDRESS: 24 So. Hunter Street , Stockton, California 95202
<br /> TANK ID #39 - 2372-01 Tank Description: 20, 000 Gallon Diesel
<br /> SECTION 2 - To be filled out by tank removal contractor.
<br /> Tank Removal Contractor: N/A
<br /> Address: City: Zip:
<br /> Phone #: ( Date Tank Removed:
<br /> ,ours a,•,,,,,,,,,,,,,,,,,r,.,,,,,.,,,,,,,,,»,,,,,,,,,,,,.•r,,,,u,,,,r,,,.,,.,,,,,r,,,,,,.u,,,,,,....,
<br /> SECTION 3 - to be filled out by contractor "decontaminating tank":
<br /> Tank Decontamination Contractor: N/A
<br /> Address: City. Zip:
<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 /> accepting tank and/or piping.
<br /> Facility Name: N/A
<br /> Address: City: Zip:
<br /> Phone #: (
<br /> Date Tank Received:
<br /> Signature: Title:
<br /> ..........................................................................................................
<br /> Page 10
<br /> EH 23 049 (Rev 2/8/97) wp
<br /> A Dt. oNm 4 San jmqumn omnw Health rare Xmce, \/ '
<br />
|