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PUBL�C HEALTH SERtICES <br /> SA.N JOAQGIN COU:4iY =` <br /> JOGI KHANNA M.D..M.P.H. <br /> Heaim Officer <br /> P.O. Box 2009 • (1601 Fast Hazelton.evenue) • Stockton. California 95201 44iFoa� <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRAC=G RECORD <br /> as.slxa.ii;xxsi.sa#lzisaY*...;xisaa..;iax.***...........aailis.........*.*...asa.................. isasa.ia <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 NANfE: HERMAN & HELEN'S MARINA INC. <br /> FACILITY ADDRESS: <br /> 13135 W. EIGHT MILE ROAD STOCKTOON CA 952219/, <br /> TANK ID #39 - � �(�J� Tank Description: /bK 16a <br /> Yaaaix YiYaY;a iYa;la;iYi;aliY;;#;iia#ixiiii##ii;si3iiitY#f Yiii YYxiii tYif ii YYYi Ya;ili YYi;;i Yf aslYialxaY <br /> SECT-ION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: WARREN E. GOMES EXCAVATING, INC. <br /> Address: P.O. BOX 369 City: RIO VISTAZip: 94571 <br /> Phone ,": ( 07 ) 374-2881 Date Tank Removed: <br /> ais....**...axxa iaxissi;#axssaaaa;a#ixxsxa;i.... Yaaasaa;sasaaszaa:#;x.......a...ixiis;x;iia 3Yi............ <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: 1 FYI(t K SG n t =!7G <br /> Address: � /G X35 Parr OW U� City: 1 Me-mC Zip: 6741001 <br /> Phone :: "—fc l,r;-) <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 /> iia:Yia#xiYax;aisaaaaslaxsaaalaiiaa Yaiszsasaaiasaxa;lz•YYasaza#saaaasia:siYasa iii!#xaxss##a#liaslisYas Ysaa: <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: _ERIC:KSON- INC. <br /> Address: 255 PARR BLVD. City: RICHMOND Zip: 94801 <br /> Phone #: ( 415 ) T15-1391 <br /> Date Tank Received: <br /> Signature: Title: <br /> as...ii...#aaz..;.....i......isi.s.i.i....is.................*...................*.i#.........aria.ii..... <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) wp <br /> A Division of San Joaquin Co=w HcnIN Cie Smsc C? <br />