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PUBLrC HEALTH SERVICES °atec <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Boa 2009 • (1601 East Hazelton Avenue) •Stockton, California 95201 ,tf)E <br /> (209)468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD C16 5 r <br /> ii#}ti#Fit}#i!#}RRiiitf##!#tYYRR###Rttk###R;iii#}}iii##iiRfttt#}#####!##f}tt!!###4fi tuff!#iR##iiiiii }!! <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: <br /> FACILITY ADDRESS: <br /> TANK ID #39 - Tank Description: <br /> #i Yitfi!lRit##ift!#}t#tttti#!#tYi RRR##R#Yit##i}}#!##i#iii###itt####Riki#i#kf#R##R#iit#tiflR!}#R}i#tt;kft#i <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: City: Zip: <br /> Phone #: ( Date Tank Removed: <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <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: <br /> Address: City: Zip: <br /> Phone #: (� <br /> Date Tank Received: <br /> Signature: Title: <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) wp <br /> A Division of San Joaquin County Health Care Services <br />