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PUB: , HEALTH SE;-WICES ,o� .�� <br /> SAN JOAQUIN COC NTY N(�I� � I s' <br /> IOGi KHANNA V D.M P il i► <br /> Hrahh Ocrcer c�. <br /> P.O. Box 2009 <br /> • 1601 East Hazelton Avrnuc) • Stockton, California 95201 �t,d°n`' <br /> (209) 4683400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ........................................................................................................... <br /> SECTION 1 -Public Health Sen7ces 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 four ensuring that this form is completed and returned. <br /> 11�FACILITY NAhg: /Tray—nt�I/P \ �nS�f)C��p\ <br /> FACILITY ADDRESS: I O ��t� soA " f�Un '�afG� 11 <br /> TANK ID #39 - 1973- 1 1{ Tank Description: ;�,()o l-q Ildn Wale 01 <br /> ................................�11r..........................................0........................... <br /> SECTION 2 - To be filled out by tank removal contractor: V) <br /> Tank Removal Contractor: <br /> Address: q er City: �c. �� Zip <br /> Phone #: ( 1 _ 1 I– o`^� Date Tank Removed: <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank': r n <br /> Tank Decontamination Contractor: <br /> Address: v'q55 1 at ` 1J�U City- �i c.�,rr, nc� 7rp: �O <br /> Phone #: <br /> Authorized r res ntative of contractor certified by signing below that the tank has been decontaminated in an approved <br /> manner as r quir by the State Department of Health Services. <br /> 1 Title: jll�d��✓!XJ/� <br /> Signature: <br /> SECTION 4 -Y o be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. C <br /> Facility Name: <br /> Address: City. gip: UO <br /> Phone #: <br /> Date Tank ecei -�-- <br /> i.i%7 �e/lam <br /> Signature: Title: _Sek <br /> ✓/. r` <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) vp <br /> A Dnxon n/San Ja>aw^.Cnun� Holth Esc Yn,m �7 <br />