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PUBLIC HEALTH SERVICES oPa�iN <br /> SAN JOAQUIN COUNTY = — <br /> L1I1vjgD <br /> JOGI KHANNA M.D.,h1.P H. A ` <br /> Health Officer <br /> NOV 2 6 199 <br /> O. Box 2009 . (1601 East Hazelton Avenue) . Stockton,California 95201 c+4(F�piasi r <br /> (209) 468-3400 <br /> ENVIRONMENTAL Hrrwry_V NUERGROUND TANK DISPOSITION TRACKING RECORD <br /> PERMIT/SERVICES <br /> r+i aaarrtaaar++iiaRrRar•t Rasrrest»•assRRtrtYYY}•>YSY>RRR>iisrRR>Y sssrrrrr>sYiRR•ratsi>tRra>trarr>iiar••>rt <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: e:5'S'�L�1r7G' /`O <br /> FACILITY ADDRESS:_ l,/. A.�,I�VIV7 c7� <br /> TANK ID #39 - -2�5� �Q' Tank Description: -.5cz,7 0�l-&;. '-y � �/�y?� ���•OL/iYt <br /> ++a•R>s+sa»sraa Yasarr tR rRrsataarta}rir Yat Ria»:Y>tlirr Yar itaSir t"rirrr Yi>aaisii rr»t>rsari»>araas:sttriti <br /> SECTION 2 - To be filled out by tan�l� rrtoval contractor: <br /> Tank Removal Contractor: Gr�6•V�T <br /> Address: ��� .��Qr�,s'y 'PIZ) I City: z4AvllZip: �✓vCy'� <br /> Phone #: ( �> . 9--9305 Date Tank Removed: <br /> XaRX»%+itit Y>iriRt>Y!}Yiti RRttYrt}iRY>YYtr}rt}YYtitttiiatir>ri4t}}fit»Ytittii RRt tt Yr it3iitrttt Ritttti Y}}t>ti <br /> SECTION 3 - to be filled out by contractor "d�cggntaminating tank": <br /> Tank Decontamination Contractor: �/�iy17 <br /> Address: �;7 City: Z�'.at�/� Zip: <br /> Phone #: s9) <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 Departmen f Health Services. <br /> Signature: Title: <br /> aataiaaa Rs >sr arta>• »>r Yatraa+Ra• stir Yr RY}R»>sitt}tRR»atrr sYtttRaRRirrrrtr Yia}i>t aaa•>rrrasrirY art tRs <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 /> Fncilily Name: Z7 4�WZI—Z_ <br /> Address: /ZRIVCity: Zip: <br /> Phone #: <br /> Date Tank Received: <br /> �A } <br /> Signatu Title: <br /> a+a>aaa>t»trent arrraYsriritYt>YYas asR Ri>s>aaYts}carr>atarrrRt♦+sYirarr>taati ltt}RYi»YYisii>afitt irYitz+a•>a <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) up <br /> A Division of San Joaquin County Health Care Services <br />