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PUBL11 HEALTH SER CES <br /> SAN JOAQUIN COUNTY 2... <br /> JOGI KHANNA MD..M.P.H. <br /> Healrh Officer P - <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 F o R <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ssssssssssss•sss:sssssssfsssssstssssssssssfissssssssstssssssststsssfsafssssssss;•ss:sss;sss;ssfs:ssssasssas <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: A R(-0 C-A C U,l TL/ 4 20 7 G <br /> FACILITY ADDRESS: IbOO r.-A`vT V-E TT(-eMA l`7 LANE 1-O P T CA <br /> TANK ID #39 - 5 Tank Description: G ,O O O GAL, <br /> ,,:.,fssssstst;a,ssssssa:sssssssssssssts=ssiststiss=stsisststssssisasstsisasi:st::ts::=sss:::::;ss:sassst <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Uo LD E1J W E5T 5 U I U P E 2 5 <br /> Address: P-O. I., X. 1�-3 fo City: 812ENTW00'V Zip: 64913 <br /> Phone #: ( 415 ) 134- jqcjb Date Tank Removed: <br /> fssssssstssssssstssssstss,ssssssssssssssssssssstssssss=ssss:ssst,ssssssstsssssssssssssssssssss;stsss:s;s;ss <br /> SECTION 3 - to be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor. Cioupem u1EST p wupeR-S <br /> Address: R O. BOX 123(0 City:M15LITW00fl Zip: 94513 <br /> Phone #: 1S 634- 19Tb <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 /> ttif ttitiitiif itit of ttiili•tf itfftittii=ttittfiifii=ttifiiaittatff=tf of atif if ittf tttiit;first;•tasf ai aaf; <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: H + H S R 1 P SE EV lGE <br /> Address: 220 GHw A C'pyv W City.ma 62AU CMD Zip: -1410-7 <br /> Phone #: ( 415 534 `x'835 <br /> Date Tank Received: <br /> Signature: Title: <br /> ss•sssss=sstasssssssssststs:ssssssssstssfssasstststsssss•sssssttsssssfstssssssssssss;;;ssssssssssssssssssa <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) wp <br /> A Division of San Jmquin County Hcalch Carc Srnices 1> <br />