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PUBLI EALTH SER CES <br />SAN JOAQUIN COUNTY Q ;r <br />JOGI KHANNA M.D.,1I.P.H. �.:, < <br />Healch Officer <br />P.O. Box 2009 (1601 Easc Hazelton Avenue) - Stockton, California 95201 'Fbw <br />(209)468-3400 <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <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: BP okl— <br />FACILITY ADDRESS: 1 - `f <br />�. /P �,_ -r�. ( r <br />TANK ID #39 - Description: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: - <br />Address: City: Zip: <br />Phone; #: (� Date Tank Removed: <br />SECTION 3 - to be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: <br />Phone #: <br />City: <br />M <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: <br />Title: <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: <br />Phone #: ( <br />Date Tank Received: <br />Sionature: Title: <br />Page 10 <br />EN 23 049 (Rev 2/8/91) wp <br />A Division of San Joaquin Counry Health Care Services <br />Zip: <br />