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PU- B- L-LC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> JCGI.u-IANNA 1.t D Sf P9 <br /> . Hetith Officer <br /> P 0 Box 2009 i (1601 East Hazelton Avenue) a Stockron,California 95101 <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> a###;a;ass;aisa#a#;asaiiiaaiaaa■a##;iissi#•iii;siiiiiiisss#i#aiiaisaasaii;a#isas;aiiai#((+Pali;aisi;iiaii#a# <br /> SECTION I - Public Health Services Trauking Sheet will accompany each tank affixed with its site identification number The <br /> TraLkIng Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling <br /> laultty The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME. I M& M Automotive <br /> FACILITY ADDRESS 10 East 10 th St Tracy Ca 95376 <br /> TANK ID #39 - 2�jr �'� Tank Description Iran <br /> •a+issai##sasis#aaaai##iii#isra;#iiass#i;i#asassssai#ai;asaiiassaa#s#iaaasaasaatii;iaiasasr###sasaiassasi• <br /> SECTION 2 - To be filled out by tank removal contractor <br /> Tank Remuval Contractor - A A I Tank RQmoyal <br /> Address A900 N g 99 r 206 City Ca 7�p 95212 <br /> Phone # 2( 09 —)-9 31 6810 Date Tank Removed. Anon permit annroval <br /> Wc;�, <br /> aatis88.88##aa assss#ai;##as;sa aaaaiai;;# sasasa#ON 3 - to be filled out by contractor "decontaminating tank" <br /> lank DeLoniaminatton Contractor Same <br /> Add[cas 900 N H 99 Cay. Stockton Ca Zip 95212 <br /> Phon6 # ( 209} 931 6810 <br /> AuthuriLed 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 /> ! �/; <br /> Signature �� Title � <br /> •+aaaai##iiaaaai(••asiiisa;itiiaaitiiiiiaiaais'#i#a;iiass#(iiia(aaaai#•siaiiisas!#iiiiisaaaasi i###taiisiis##; <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 /> Ric.ility Name Triangle <br /> A"dr"s 3525 52 nd Ave Cory Ca Zip 9[°2 <br /> Phone # (2LL_) 21 1990 <br /> Data. Tank Rec.etved <br /> Signature Ti tie <br /> •#a•assiisiti#isiiasa;a;;aaaias;aasssf;sa;a;s#aaaia;#aisasa#sssasaa;##sssaaiataaraa*ars(airaaa•asas#as+ <br /> Page 10 <br /> EH 23 049 (Rev 2/8191) wp <br /> A 01viston of Sari Joaquin Counry Healrh Care Services <br />