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PURL �� HEALTH SER�T.,�. <br /> pP.u.!N <br /> SAN JOAQUIN COUNTY r.. . <br /> JOGI KHANNA M.D.,1i.M. <br /> Health Officer <br /> P.O. Box 2009 . (1601 Easr Hazelton Avenue) - Stockton,California 95201 � <br /> (309) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKLNG RECORD <br /> ssasssassssssssassrsaraasrasaasaasssss assasrtssesssrsassstasasasssssissssssttssstssttsrsttasssssrsssasrarraa <br /> SECTION 1 -Public Health Services Tracking Sheet will accamgany 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 ono" SE I2,V 10_= PATI oN * -7-'0 7 37 <br /> FACILITY ADDRESS: 1007 f;CUTH 6L.— DOFZA.C)0 ^%4E-NU STOCk-7Ct14, L.p. <br /> TANK ID 7#39 - Z —(�� Tank Description: <br /> assasses:ssasss■sssassrasssasssasrsssssses■assaaasssrssssssss:sstst#srtasr#ssssts#sat#sasaraaaaaa rraaa saes# <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> address: City: Zip: <br /> Phone #r: ( �) Date Tank Removed: <br /> assssssssssssrrs#rrsasssaassasrsesassassasssssaaasesssssssaraarraassssaaaaass■sasassssrsssss#ssssssssssrass <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone #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 /> saes"ssasss"asssassassaaarasrtrssssasasssrtsssrsa rstrrsa to sssssarsrtartrt#s*s srstrarrssrsssrsssssssastssssssr <br /> SECTION 4 - To be signed and da[ed 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 w: (� <br /> Date Tank Received: <br /> Signature: Title: <br /> seasaaaserasssss#srrrsrrssassaasssasaassasassasrrsartsessrtssssssrtsssssssa#sassssssssssssrsrlaasrtsrsrrraaass <br /> Page 10 <br /> EH 23 049 (Rev 2/8/97) up <br /> A Division of San Joaquin County Health Care Services ro <br />