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PUB L�, - HEALTHR, ES <br /> SAN JOAQUIN COUNTY F f <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 - (1601 Easr Hazelton Avenue) - Stockton,California 95201 <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> Yaaa■YiYlrr//see/■#i+#YYYisYli!!+/cess!sets#s/ssstrsasssasfrYYi#YrY#sYiirss aa//si/tis <br /> SECTION 1 -Public Health Services Tracking Sheet will accompany each tank affixed Mth 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: Erotor.l tepwIcg STA.TtoN # x-0137 <br /> FACILITY ADDRESS: 1(005 SOUTki CL_ PCRA.Do ^\46NVI , STOC,k.Tdv, C.,4 <br /> TANK ID #39 Tank Description: <br /> sasaY+asaYs#aassssears/ia#lastss#YYerasriaissssssssssssessesssssssssaaassasrtr#rte#ass sY##asYisaisirsasisses <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: City: Zip: <br /> Phone Y: C_� Date Tank Removed: <br /> SECTION 3 - to be filled out by contractor "decontaminating tank': <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone #: L � <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 /> asas/srtrts#rssra/#sa sssss as s/resars#ssrsrrrrrrrrsr#ri♦rrYrrsrrs♦■/sae sses/♦ssraarart■#rrsrse#isssss sssr#r#raa <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: <br /> Address: City: Zip: <br /> Phone 71r: <br /> Date Tank Received: <br /> Signature: Title: <br /> aaa#ia YiiiYa/ass/a#a#a#YrYrYL/ii/i■Y/•is##ii/i//////////////////riYrii/#r###r#fi tsrt#ra#rtrt###vii#if aiiiY#ri <br /> Page 10 <br /> EH 23 049 (Rev x/8/91) up <br /> A Division of San Joaquin Coun:y Erol:h Care Services <br />