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P "C HEALTHSE:VICES o... ..� <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> Heaich Officer <br /> P.O. Box 2009• (1601 Fast Hazclton Avctuc) •Stockton,California 95201 <br /> (209)468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ♦lily♦iYiiiiiity;#yii;YYy;#;iiY;#iiti#;;i;ff;i•ti##i#;Yi#i##t#;till#iiy;;#i;i#i#•#if#iff;iiitYifYttiY;#iii• <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 reryclin, <br /> facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: G. <br /> FACILITY ADDRESS: <br /> TANK ID #39 - — 0 I Tank Description: _ 1�;ODO <br /> SECTION 2 - To be filled out by tank remov4lr: <br /> Tank Removal Contractor: G <br /> Address: City: Zip: <br /> Phone #: ( ZG� S�4� 9�S3 Date Tank Removed: <br /> iiYi#;ii#i#iiiyi;;;fiYiiiii•fi;;iiiiiii;i♦iiiiii##fi;iii Yti;iii;;ifii##i####fill##i;iY##iittyYY#ii;;#iiiiii <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank": L � <br /> Tank Decontamination Contractor. <br /> Address: Zip: <br /> Phone #: <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: Yi <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tank and/or pipine_ <br /> Facility Name: CAL COAST- <br /> Address: <br /> OAST_Address: A-2_4 S T E G N E R City: .,T U RL OL K-_ Zip: 9 5 3 8 0 <br /> Phone #: ( 209- } 668-9378 <br /> Date Tank Received: -2- 7 <br /> Signature: 7i( -> Title: �— <br /> f 1^, Qtiyn.c- <br /> ' ;tilt;iiiiii;tiyy#i;iiititiii#YY#ii##t#tyt;4;yittit•#iiiy;iiiiiy#iiit•tilt#ti;;i#itiYi;t#fyii;iYyiiyiiYiii <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) wp <br /> A Division of San Joaquin Counry Haim Cue S—ces <br />