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PUB�IC HEALTHPaU11y <br /> SAN JOAQUIN COUNTY <br /> W <br /> JOGI KHANNA M.D.,M.P.H. <br /> :< <br /> Health Officer <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 c4cixo'���P <br /> (209)46&3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *#####i»»»##»w#its*i*##*##*##*i#*##s###s***#ww#*#i##w**####■##*wwi»##**##ww##***#w#####*###*ws##*##**###*## <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: rvr ,Q_k(—C <br /> FACILITY ADDRESS: 23's-6� J jlv-4 F67 <br /> TANK ID #39 - Tank Description: Sid t? ( ,� /0�Ga4C[ vrll Ti9rt/�S <br /> SECTION 2 - To be filled out by tankrem val contractor: <br /> Tank Removal Contractor: C 0 <br /> Address: ��` /ry_� �'dl City: ✓r`�i'���_ Zip: . <br /> Phone #: ( U� ) � "�� � Date Tank Removed: <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: �miC o <br /> Address: oeyl ![/_ /lye 7'r,/e h City: Xmey G Zip: 2:. —1 <br /> Phone #: W --7e,53 <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: 1 , PW <br /> ! �� _ Title: <br /> i#ss#s##+►#w*##*s*#*#ii##i#k+k�t###44###i#w##i#iii#irk####ii###kkkw####*#i##wi9kyM##i##k##wkw####ii####ww#ii*#### <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. '// /-1 <br /> Facility Name: IrC l(F'4/ (a <br /> Address: 00.,S- 77Re--V-�. <br /> City: Zip: <br /> Phone #: ( /i <br /> Date Tank Received: <br /> Signature: Title: <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) WP -yy <br /> A Division of San Joaquin County Hcalth Care Services �/ <br />