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SAN JOAQUIN COUNTY <br /> r <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O.Box 2009•(1601 Bast HaWl"Avenue) •&OdMOQ-C WOMia 95201 ► o s;�`�~- <br /> (209)468-3400 <br /> UNDERGROUND TANK DLSPOSMON TRACKING RECORD <br /> •..s••a•sa•assisa+aasasaSassaSsasaaas+aasssi•srSi•ir•••Stals+ai■ria•r•ssisiaasSaasiia•si•ssaaaSsaaa•ra••.. <br /> SECTION 1 -Public Health Services Tracking Sheetwill accompany each tank affixed with its site ideatiftcatiam number. Z': <br /> Tracking Sheet is co be returned to Public Health Services within 30 dues of acceptance of the tank by the disposal or reryct,j <br /> facility. The permit holder is responsible for ensuring that this forts is completed and returned. <br /> FACILITY NAME: RIPON UNIFIED SCHOOL DISTRICT <br /> FACILPTY ADDRESS; 301 N . ACACIA AVE . , RIPON ,- CA <br /> TANK ID #39 - 2243-02 Task Description: 1-7 5 0 0 <br /> 44040a064sraa••asaasisssassassaassssaasasasaSaaSssaSsaa*ess�as�asasSaisaaaasaaaassaassissaaassasa00004440s. <br /> SECTION 2 - To be Ailed out by tank r9m0yal contractor. <br /> Tank Removal Contractor S E M C O <br /> Address: 431 W . HATCH RD . City; M 0 D E S T O <br /> —zip: 95351 <br /> Phone #: 2( 0 9 ) 524-9653 Date Tank Removed: 12-0 5-91 <br /> ;ECMON <br /> 3 - to be filled out by contractor'decontatuiaating fault;': <br /> Tank Decontamination Contractor, SEM C <br /> Address: 431 W . HATCH RD . City: MODESTO Zip: 95351 <br /> Phone #: 2(-_ 09 ) 524-9653 <br /> Authorized representative of contractor certified by signing below that the tank has been decontaminated in an approve] <br /> manner as required by the State Department of Health Services. <br /> Signature: 'Q <br /> Title: (D"LZAJLs <br /> sasssaa•s•sit•••ia■iiia•aaaaaaiaaaaaaaaaaaa•aaiiaiaiaaiiii•aaiaiaiiaiia•aiaaaaaiaaaa•i•iaasiaaaiaiaiaaa.... <br /> SECTION 4 -To be signed and dated by an authorized representative of the treatment,storage, or disposal facility <br /> accepting tank piping, <br /> Facility Name: CMC <br /> and/or p i to <br /> Address: 600 S . 4TH ST. City: RICHMOND_ gip; <br /> .. <br /> Phone #: c s in <br /> Date Tank R v <br /> Signatur <br /> ,••i•aiis •aa•iaas ••■;aiaiiiaaaa•fiaaai lata ass •i•iaia•••iii•iaaani•iiaifaaaa••issaiiaiaiaiaaaai••.. <br /> ge 10 <br /> Elt 23 049 (iter 2/S/9l) wp <br /> A Dkft a OF Sm jasquw GgwXy I{dfi CUC Savk= <br />