Laserfiche WebLink
' t�. <br /> PUBLIC HEALTH SERffCES <br /> SAN JOAQUIN COUNTY �. <br /> JOGI KHANNA NI.D.,M.P.H. , <br /> Health Officer <br /> P.O. Box 2009 - (1601 East Hazelton Avenue) - Stockton,California 95201 cJF �N <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> iiiaii#i*tkttf af#Iitkitkitt*ktiif#fr#ff#iitt#YYtstitt YYii#iiiit#ti*iii##!##4}Yft#t####i tttiiYtki li a##iiaiit <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: E rV4,v NA SE XV I(rE !�!SAT1 o-4 Z'015-7 <br /> FACILITY ADDRESS: 1(005 SouTH CC— ooIZa.C)o A'�1I✓NUE, SToc.k.Td,4, C.p+ <br /> TANK ID 7#39 - 4cf (� (�f Tank Description: <br /> *}ti#yi!}ir#it#}ti♦titiili###i##ik#ttkttttf tititti##iiitiifi i#tai##itk*f*i**ii##*t###t####if#ii Yi Yitii#### <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: City: Zip: <br /> Phone m: U Date Tank Removed: <br /> !t#!!#if##hitt iiiiiit*itis*i#ii!}}}}r\#ii##tt iitiititii tt Yiiiiiiii**#tiii#i#it*ifs#!!i#ii#i###iii*iii}iii# <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone #: <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 /> itistali}itiik*!f####i11\Iitiiis#*#ii tit##iii########i#ii*i#####tf##########t#ir!##kiiii#its iiiit#t#*#*f!f# <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 /> Fatality Name: <br /> Address: City: Zip: <br /> Phone #r: <br /> Date Tank Received: <br /> Signature: Title: <br /> assaasYiYssrsrsi#s-esssias#ist**##stfs#t}t##ssttsats*#}t#it#s#aisi*#i#f}f*sis#i*#t*}t}t#aas#s#!#rrliisss!# <br /> Page 10 <br /> EH 23 049 (Rev 2ta/91) wp• <br /> A Division of San Joaquin County Health Care Services <br />