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PU F iC HEALTH Sr LNICES
<br /> SAN JOAQUIN COUNTY =:
<br /> JOGI KHANNA M.D.,M.P.H.
<br /> DEC L •n�� Health Officer
<br /> P.O.Box 2009 • (1601 East Huchon Avenue) •Stockton, California 95201
<br /> ENJIRONMEfu HEALTH `' �""
<br /> (209)468-3400
<br /> PERM IT/ScftVI!„=J UNDERGROUND TANK DISPOSITION TRACKING RECORD
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<br /> SECTION 1 -Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. Th
<br /> Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recyclirii
<br /> facility. The permit holder is responsible for ensuring that this form is completed and returned.
<br /> FACILITY NAME: Lot Tta6 UK 2
<br /> FACILITY ADDRESS:
<br /> �7 3 fn G1, /f?R i h)l 0rAn // FiPs �r�N ('AmP 6'A-
<br /> TANK ID #39 - 16 /6 _a,� Tank Description: �S� 9A(F CON �V4r - 'C-7 O/1-
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<br /> SECTION 2 - To be filled out by tank removal contractor:
<br /> Tank Removal Contractor: 6�
<br /> Address: q)( 6e), Nil TL Ef )a 0 City: tn6D E570 Zip: 9,5-
<br /> Phone
<br /> ,SPhone #: ( 2091 j Z 9655 'Date Tank Removed: _ �- 9
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<br /> SECTION 3 - to be filled out by contractor 'decontaminating tank”:
<br /> Tank Decontamination Contractor: SC/1I60
<br /> Address: `f 3/ IV, � 'r c H 2 b City: 95
<br /> ODES�o zip: 3:5/
<br /> Phone #: (209 1 SZ 7/ft. 96 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. p—
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<br /> � Title:VV
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<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: �.t-s /y1�IwLS
<br /> Address:_ I I )�t t!x @ LO ter uA City: Pk) Zip: X3.5
<br /> Phone #: (2o 9--)
<br /> Date Tank Received:
<br /> Signature: I -"
<br /> 8 �=h �i i 1 . Title: i-
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<br /> Page 10
<br /> EM 23 049 (Rev 2/8/91) wp
<br /> A Division of$an Joaquin Comfy Heahh Care Sc-cm \/
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