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TH SEMPiCES <br />PUBLI(!HEAL <br />SAN jc;A UIN COU.", <br />JOGI fin 4NNA }t D , ::.? H. <br />Heal:h Ojr'�cet <br />P.O. BOX 20090 (:6')1 East Hazelton AvL-r.uc) s Stockton, California 95201 <br />(20t,)) 46a•34M <br />UNDERCROUND TANK DISPOSITION TR;,CIUNG RECORD <br />}8fa.yRHr49xtAl**asfr$lfli+C4ffiHtBkA ASA''•m'Q$'lebPRHfIWVP[®4Rldafl61RsA6effis9$a[[tKcm HAR PrR [fR MRt$}lI+RRRROt•1[AH eO <br />SECTION 1 - Public Health Semi -es TrackingSy: et will .�ccctnpan;• each it nk s€€fixed with its Site ideritlGattion number. The <br />Trackitt; Sheet is to be returned to Public F.e lth Se^tier;; within 3a davi of'cceaturca of the tank by the disposal or re:scl'sng <br />facility. rine permit holder is respor.:ible for an►sla;ing th2t this form is comptet.d and returned. <br />FACILITY NAME: 5- NL3�-�f S'T[s-,'7i j— <br />FACILITY ADDRESS: <br />i'ANIw ID X39 ._��/ - Tank Description: 5000 Gj4 tr-tOJ _ <br />i <br />pY)}a161}iAe{rOHfti•Y1}►1tY�tfHAtRf YH 4Qt.%dfsk$sfY'!$kAV}$ylrca plea+Ana YAti691AHd+Y7'sln'Q'4HM gH'lld'Rt RtdY'9$19di 4'Yffi R$R$Ya.l Ssffi <br />SEMION; 2 • To be filled out by tank :er.;0v3it contrzeWr: <br />Trtnlc Removal Contractor:._�1 _ z► 5= <br />Z- i£�G I; �� , City: ��'�-=C Zip: <br />AJdre55: <br />— — <br />1 <br />none #: } 32 Date Tarek RemC,-td: _ I <br />(_L_. <br />Ry.pRAR RlAfR'►[aAaR16MF'f [d,1�3 [41�d'aaAR'Yds'fdO�ef}aaed HsaY YYi<<a ei�saHetaaa 6v dd$s aAfYAsre'l RaxYa6ffi s!4 ffi'dR Rsee •'�ss41 <br />SECTION J !o be filled 02,11,02,11,by contractor ^diocowaminatnng <br />Tank Dcconu+r"inaiion Crrtractor: <br />Addie: J: <br />Phone #: { _} --- <br />City: Zip: <br />c�tJt;loijZ:ti rt'rreit'tlt:ij�'e iii C=;ntraClt: CBrtt_`:t'd �?)' $' f iTil7 t?::G'-* the iank t.:S item deconta::.ini?ted in an apptOVed <br />s <br />m' nlicr a r.Fcf,::re-1 by line S:a:e D=°a?.it.''if ;:t 4f -Reale:; Se.r�'ices- <br />Titre: - <br />Signature: <br />y!a[s+tAaeaesssats Yieaafy'dttsRisef ssvts$tesdssaaAa a a s e 6 Hr:..t6'•aes:.alSae4$sa Ri �ffissed.y �Rss laddRafev�'fae Av d'dtA <br />SEC' ION 4 - To be. Signi"d and dated of GZ avihorizta reprtse-, tiV•, C' flee ireitt3;aeni, jiC�aEL', or disposal facility <br />acc8rtinb tank and,, r piriniz. <br />Facility Name. <br />Address: <br />,� ity: <br />Zip: <br />plione <br />Date-- <br />Titie:�_�--�----- <br />R s a e i a Y f t r t< a e a r d /•a *• 7 J s a e tl f B s s e t a m a . e.♦ • r••. A f e O r. s ... •< a<.• y e A a t s t a s e e K* a e• a d. a A s e a r a f A f -• 4 D= O e e f a e s a <br />®3'e . <br />EN z3 Cc$ (R_• 2W,;!) Hp <br />.v < n-�:'•1' <'.:e stn^.: r9 <br />�1 <br />t - - - - i <br />