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PHEALTHU LI SERIICES U I Ad: <br /> SAN JOAQUIN COUN Y <br /> - JOGI I:HANNA M.D..M.P.H. <br /> Health Officer <br /> P.O. Box 2009 • (1601 Fast Hazelton Avenue) • Stockton, California 95201 04�!F b <br /> (209)468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> salsas**s«ssaaeasaasas:*#mma*#sa�:�as�sassasss*sae*ass«assesses*sass«*sassesass**sesta**as*assssa*ass:*#*aamm <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: LAWRENCE LIVERMORE NATIONAL LABORATORIES <br /> FACILITY ADDRESS: $ITE 300, CORRAL HOLLOW ROAD <br /> TANK ID #39 - Tank Description: 2,000 GAL , DIESEL <br /> s«sae«#assaaa*ss#sass«#s#aa#ssaaaas##as#mmsasaasmmsasas*ss#asses*assess*ssaaassaaass«s*s*sa#aassammtsa#sasses <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor: HFSS & HESS CONSTRUCTION, INC . <br /> Address: 3819 D11cK GREEK DRIVE City: STOCKTON Zip: 95215 <br /> Phone ir: (_209 __942-1818 Date Tank Removed: <br /> mma«t:*a**sasses:e#aamm*a;aa#aa:mmaa:*aa«aaa«a«aaa*::amm*a*«:ease*aaaaaaa**aa:a«t*a*aa*ta===ease*a*ease*a«:ansa <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: HESS & HESS CONSTRUCTION, INC <br /> Address: SAME City: Zip: <br /> Phone T: (_� <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: PROJECT MANAGER <br /> ssaaaaaaaaasaassa:assaseas#a«s«*#aa#assssssasaassssxaa*ssasmmssssaammeaeases#smmssaaaas«ss#a«#«mmmmassssasa#sa*mm <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: H & H ENvTEQNMENTAL SERVICES <br /> Address: 220 CHINA RAS T N City: SAN FRANC I S(Mp: 94107 <br /> Phone #r: ( 4 1 ) 905-5510 <br /> Date Tank Received: <br /> Signature: Title: <br /> sennaasses**sae«seas*sansa«*a*ssaaaaasaasassa*aa*•aa*sssassesssaaaas«*as*at*aaasia*aaasasassaaas***ssaaaas <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) up <br /> A Division of San Joaquin County Health Circ Scriccs <br />