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V <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY =` <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 0 (1601 East Hazelton Avenue) * Stockton, California 95201 i..F o...R <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> J} <br /> ttttatti••t>iia»tfttf>!!»at>+fff•Rf!!>•f!!!!!ttl:#t#rR#R####ti##+#a/ti�(f>Ft—f itTiti!('\l it l�##R#R#t#ri#}+af ti• <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: G1a2. &c /.(,oCAV A A o,Qolf e,s <br /> FACILITY ADDRESS: <br /> TANK ID #39 - 10 602— Tank Description: �i CQ�l OA �n(\,5, <br /> itiilr#i#rirrttrrrttt!>i»Rtttaf!>»!»!!###!!ii}iii+rartt!>t!#:!s#####}iiirr#+YYfi#t>t:»>f>R:R!#####ilii <br /> SECTION 2 - To be filled out b tank <br /> remoxaYon �tor <br /> Tank Removal Contractor: <br /> . <br /> Address: ID, bu IOCity: .y�;�A '� Zip: cl <br /> ll79 <br /> Phone #: Q09 ) 31-1 SQ 9 Date Tank Removed: <br /> •Yit##fttilit!#R!#}!}#RRr#t#+#i#ti+ilii YtR t#tRlRRR}}}##l++ilii#t Rtf tR}R####+##}+##iii#tiitlt##!t!##it####ri <br /> SECTION 3 - to be filled out by contract99y�__decontam;i1mg tank": // /1 1 <br /> Tank Decontamination Contract/or/: ISp ('t)(1,SCf('X'1!J(1 lL). IlIVC c� <br /> Address: Po , QOx I�lolO. City: <br /> Phone #: (�93 I-1$a& <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:_ M <br /> q!!q#fltgrtrigiYtitititf!#RlRfi!!R#####+##i+ilii iii!}#R#}+i#itriiiii•tlRt4ii tR#4###inti itf ilt!!tt•#}Rf <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 /> t♦#tiitttt•tt•!f#t#####R#ii+####tt#######R#tit#R#RR#}!######ilii#RR###tY###i#ti>itii#if Ytt>#f itf i!lRRRR#!# <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) up <br /> A Division of San Joaquin Counry Health Car,Services 10 <br />