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PUBLt HEALTH SERVICES '��� <br /> SAN JOAQUIN COUNTY <br /> N: <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> �tiFoar: <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> !t!4!#f#tltt#fltflt}tf#f#!!!f!f!f##ttt!•lYltf#t!•!#f#!t#!#Y##i#t!f#tt#f!#1#a###f!!0!t!!t!!t#•##taf alf of#tf# <br /> SECTION I -Pu <br /> heet will accompany earih tank affixed with its site identirication <br /> Tracking Sheets istlo be retHealurned to Public Healh Services Tracking th Services within 30 days of acceptance of the tank by the disposal or recyclT ng <br /> facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: Co unercial Transfer Inc. <br /> FACILITY ADDRESS: 1651 Louise Ave. Lathro Ca. 5330 <br /> TANK ID #39 - 1659- 01 Tank Description: <br /> FF10 0p00 k (alp. (diesel fyuy 11 <br /> !#f##f!f#ffiflf#lasat:f#s#oftt:t#t#t####r!t!t#:alYF"t,ia'�ial�klX4i�#'{QQ#Yf4�#'tAis#!:#ttlatlt#!tll4=t!#tt:##t <br /> SECTION 2 - To be filled out by tank <br /> Jim removal <br /> Oilcontractor: <br /> Rich-Mart Construction <br /> Tank Removal Contractor: Thorpe <br /> Cit Lodi,Ca. _ Zip: 05241-0357 <br /> Address: 351 N. Beckman Rd./P.O. Bx.357 y' <br /> Phone #: 20( 9 ) 368-6175 Date Tank Removed: <br /> !slffts#f#•ftr#t#t!#t!tl:t#t#satlf!!s#t##t!!#•#Ylafttttf##!ta•!aflf##Y#s!a#as!#taut#ta:!#at#atls#!tt#s!s#:• <br /> SECTION 3 - to be filled out by contracroimeThorpe n0il, t Inc./Rich-Mart Construction <br /> Tank Decontamination Contractor. <br /> 351 N. Beckman Rd./ P.O. Bx.357 City; <br /> Address: Lodi_ Ca _ ZiP:95241-0357 <br /> Phone #: ( 209 ) 368-6175 <br /> signing below that the tank has been decontaminated in an approved <br /> Authorized representative of contractor certified by <br /> manner as required by the State Department of Health Services. <br /> Title: Contractor <br /> Signature: <br /> faff#t#f!!!f#!!#f!t#talta##f#t#f!!f#t#t#itY!!!f#atfOtt#tfft!##t#!!!!#f!t#tt!•altalt#flit#ttttlt!!t#tlatltt# <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. Owner to retain tank <br /> Facility Name: <br /> City: — Zip: <br /> Address: <br /> Phone #: (_� <br /> Date Tank Received: <br /> Title: <br /> Signature: <br /> fff#t!t!!t•t!•!#t+•#t##tttlt#t##!#t!t!•!#f###!#!#•Page 10#tat!#f#tt#t#tl:ttt#•#ff#f!!f#Yta#•#t#t#lft##tltt <br /> EH 23 049 (Rev 2/9/91) wp � <br /> A DlNslon of Sul Jmquin County Health Cue Servlcca <br />