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U IN <br /> PUBbIC HEALTH SE&VICES o'a <br /> SAN JOAQUIN COUNTY s, <br /> JOG[KHANNA M.D.,M.P.H. <br /> Health Officer ' <br /> P.O. Boz 2009 • (1601 Fast Hazelton Avenuc) • Stocluon, California 95201 F o R <br /> (209)468.3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ttiittYf itf itttiftit►►t♦►1►t►ftttttlttt►Yiittfttitttiiliiiiiiittftiti Y■iftftYliifttiitiiiftitltiiifliitiYt <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. Tll <br /> Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycliii <br /> facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: Z-OC-KC F�V2O /N,97 /2-FACILITY ADDRESS: 21001 N E6-640T7 i4AV LCUIGEFD <br /> TANK ID #39 - Tank Description: l000 C,'uvoy <br /> ii/filifiiitiiiilllt#lift►i►iltiliilttl►►if►iftitYilittititiiiiiliiitiiif tiYif liiiifittitttttii♦iff►iitilt <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 5 0/n c 4 <br /> Address: q�l V11-1A TG!-( City: Zip: 9S3S <br /> Phone #: ( Z-O? 5Z V 9 53 Date Tank Removed: <br /> tttiitiittifiiiiii►tiiittiit►♦ilittilliil►ffiti}its}iittiif/ififfitttilYtiYitttitYti}ittiitiiiltiiiiti►iit <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank": <br /> Tank Decontamination Contractor: 5C—In CQ <br /> Address: City: /l ,06—S7'o Zip: 9'S 3S <br /> Phone #: q&5-3 <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: <br /> ttififfi******o <br /> tif it ittliiitittit►tiifittt►•tiltsii iff ttiiif ii YYf iY titiif stiff Yiifti lit ilf iifiYi if if lilt if iilift <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: LL`(//N /YlC—Ti`iLS GDRO02�T/6ti <br /> Address: �� T�h -ST2 City: Zip: <br /> Phone #: 0 1 - D,6 D,( <br /> Date Tank Received: <br /> Signature: Title: <br /> l♦ttiliiillillYittlitiiftl►►l•i►lt►illlfllil►►fi►iifititiitfiYYitiftfiiifititttiil}i►ltliliiittttttttitftt <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) wp <br /> A Dtvuion of Sat Jcra.,..: County Health Cue Services �� <br />