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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY a <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 0 (1601 East Hazelton Avenue) <br /> • Stockton,California 95201 rtFOa <br /> (209)468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ti#tit#!i}!f##lit tYtitrtff i'{ii#itt Viitt!#Vittf tit!#t♦Y{ilYt{iitt{{{itViftfitf Ytit;#liiiii#ittff Y#lit{iYVit## <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: v (� /y' <br /> FACILITY ADDRESS: I fi T ��L 4 e-1 6 7dAl V` <br /> TANK ID #39 - .7 q f h--1k Tank Description: �i(/ l� Sti �e1e� <br /> t#ttitti##!#t#{lift;itt#f ii##iii##Yi#iii#{iY#iii Yttiii#itti###itt#tt###ttitittiititYitti Yilf#ttlt###tit#ft <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> / c <br /> Address: �r>4C City: lCCS Ir"p: (J <br /> Phone #: Date Tank Removed: <br /> t##}4it;##iii#iitYY#titttiti#tY#tY;i#Yit##iii#till;#iii1;Y#itiY##itt#rtrtYti;#Ytiii#Y tiffit}ti4##ttf Yit#ii#t4 <br /> SECTION 3 - to be filled out by contractor "decontaminating to 2 <br /> Tank Decontamination Contractor: <br /> Address: City: 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: <br /> ###ti##itiYt##iY##Yi1YtY{iitiiiYttiiti#{iti#tiittt#}if ti##ttii##ii Yi##iii#YiYii###ilii#ititit#!ii##ttii#}i <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: <br /> Address: City: Zip: <br /> Phone #: (� <br /> Date Tank Received: <br /> Signature: Title: <br /> ltiYtitt;#it;##i;;;#il;;#iliilit;##}t;##;ii###itiii}#iti;##ifti4#t;;;##tYi;##ii;;;}#t iit44i Yt tiiiii##iit#i <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) up <br /> A Division of San Joaquin County ficanh cwc Services C� <br />