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PUBLA HEALTH SERIICES <br /> SAN JOAQUIN COUNTY r. <br /> •Z <br /> JOGI KHANNA M.D,M.P.H. <br /> Hedch Officer ' <br /> P.O. Box 2009 • (1601 East Hazciton Avenue) •Stockton, California 95201 <br /> (209)468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> a«as*asaasassaasssassssaassasasassaasasass«asssasssssssssaasassssasaassaas«sasses*seas:saasassasasssssaasas <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: SITE 300, CORRAL HOLLOW ROAD <br /> TANK ID 7#39 - j / Tank Description: ___ 3,OOO DIESEL <br /> ssssssasa«sssssssssssasassassesassaaaaaaaasasassssaaasasaassasasssssassaasssasses*«ssssassssassaassaaaassa <br /> SECTION 2-To be filled out by tank removal contractor. <br /> Tank Removal Contractor: HESS & HESS CONSTRUCTION, INC . <br /> Address: —38.19 ucK CREEK -DRIVE City. STOCKTON Zip: 95215 <br /> Phone qg42_]8.].R Date Tank Removed: <br /> as:a:ease::««a:aasasses«asaas:a«aaa:aaaaaaaaaaaa:«:aaa:asaas:aaaaaaaa:ease:«a::::aaaaaaa:aaaaaaaaaaa:aaa::a <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 7'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: <br /> Title: <br /> sesassssasasssasasasssssssssaasasssasasssasasssasaasssasaasassasssasasaasaassaaasaassssas«***asaas«assesses <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 FNV T RnNMFNTAI SERV T CE <br /> Address: 220 CHINA BASIN City:SAN FRANC I SCOZip: 94107 <br /> Phone 7-r": ( 415 ) 905-5510 <br /> Date Tank Received: <br /> Signature: Title: <br /> aaa:*saesseas«eaeeeaeasseessassassesasaasaseeasaasaesassess*«seesasaas:aasaasaeeseassaaaseeesssasaaeaeaess <br /> Page 10 <br /> EH 23 049 (Rev 2/8/97) wp <br /> A Division of San Joaquin County Hcal[h Carc Scrviccs <br />