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PUBLICCEALTH SERVRIS <br /> x SAN JOAQUIN COUNTY <br /> ` a JOGI KHANNA Ni.D.,M.P.H. <br /> Health Officer <br /> A� v v Sox 2 • iRoaN`� <br /> OSIQ, (1601 East Hazdcon Avrnue) •Stockton,califoruia 95201 <br /> 4 <br /> ROW, <br /> N,tA�� tt' (209) 468-3400 <br /> PERMIT/SERGROUND TANK DISPOSITION TRACKING RECORD <br /> ••••iii•►iiiiii iii.YYY+.YY+itittti•Ytti+111♦++t+11•tttt+tYi•ttYYiYYttY+tiitit•YtYYYt♦+t Yiti+YiYYiYi+iYiiii• <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: LOCKEFORD� <br /> ., W L.A.�,T M4TGRZ./lLS CENTER <br /> ,. , � <br /> FACILITY ADDRESS: 21001 N . E L L I O T RD . L O C K E F O R D CA <br /> TA.N'K ID #39 - Z c ti - e l Tank Description: 1-500 DIESEL <br /> ••••f iiiii N ti•YSYi+YitistitiY+it•ttt♦ttt♦itY+�ttt+ttti•ttY+t•tYttit•YY+i+t+i+t++tttiiii+t+i+t NititttYtti <br /> SECTION 2 -To be filled out by tank removal contractor. <br /> Tank Removal Contractor: S F M U) <br /> Address: 431 WEST HATCH ROAD City: MODESTO Zip: 95351 <br /> Phone #: ( 209 524-9653 Date Tank Removed: <br /> •iii ii ii ii♦iiii•ii iiiii+tYY+♦till••tY+ittYY++i+t+i+++tti+t++t+ittii++••iiYtYi YY+YYii+iYiiiiYY+tYitYii+inti <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank": <br /> Tank Decontamination Contractor: S E M C O <br /> Address: 431 WEST HATCH ROAD City: MODESTO Zip: 95351 <br /> Phone #. ( 209 ) 524-9653 <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: ,flet 9,. Title: 0,4ek-A7- r <br /> iii••ii••ilii•i•♦iiiiiiiitYYttii+tiY•+YYiYttYiitY++t Y+ilii+tiitiii++i YYtiitYiiii+liiiii♦ilii+i+iiiiYiiiii ii <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: A & S METALS <br /> Address: 1616 ANGELO WAY City: MODESTO Zip: 95351 <br /> Phone #: ( 209 ) 537-4766 <br /> Date Tank Receiv <br /> Signature: I Title: !�^ <br /> iiiiit•il ii•ifi+ilii+iiiiii+ii+tYYti++ii+iti+tiiti++tiY+iiiiiiiitit+++Y++i+ii+ii+i+ii+ii+tititi+tiiYiti Y+t <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) wp <br /> A Doum o(san Joaquin Cavy Ncam cue scrvke <br />