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PUBM HEALTH SERVICES <br /> SAN JOAQUIN COUNTY r: <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 r (1601 East Hazelton Avenue) r Stockton,California 95201 <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> •raH arrUurHU NYara»•arHaaaaaaaarlH•rM!!lt,HH,rrlaq••ta##ita#a,tHr»»,Hal##,lUHtHrMtt,#rqt• <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 <br /> "that this form is completed and returned. 9 <br /> FACILITY NAME: <br /> FACILITY ADDRESS:_ZY.3 <br /> �/ <br /> O <br /> TANK ID #39 - ? A P qj — DI Tank Description: �,000 %a4 <br /> rarrr»aaaH#Hlr,HaHaaa#HrarHHaHH#H»•,r♦•Ha,•HH,Ha HaHr,,,,rrHa•aHHHHYta♦aH#u#raHHH <br /> SECTION 2 - To be filled out bb k regmoval contractor: <br /> Tank Removal Contractor: �`1•l.2gY- /�y tr_/i . �.�a - inr a / -.i� �; <br /> Address: (/D. fot 91607 j/✓)YiL.ru.�� City: ,.ig= Zip: 900'0 `J <br /> Phone #: ( z/.3 ) 297—// 9/ Date Tank Removed: <br /> •t"ra its rtaal.rrtYtiaa.l rta araaaaar Y»i YrrYHaa!»HarHr#!aH»aara#rHHHrr##ra r,ll rr aarraaaa rYll Yatraatasa <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <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 /> ...rrHaaH#H„•r•sa#H,r„♦#a•Ha•rrHHa HrHH#HH„HHH,•H,HH,H,,,.HHaa,H,H,HrHp H,,,,ra <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. c <br /> Facility Name: � }_� N �f)VIYUnmetrt � JCYV(C2/5 /� �/ <br /> Address: 220 China ?na`Jin RocJ City:�5m f�'.�1C15C6 zip: %N IDT <br /> y3 -DaPhone #: ( y15) '59-5 - <br /> Date <br /> te Tank Received: <br /> Signature: Title: <br /> Y••ararsa»HHHH,Haaraaa#aH#HaraatalH,ayHaaar#„Hrrat,,,»aa•HaHH»HHHH,YrHaH H,a YaHraaaaa <br /> Page 10 <br /> ER 23 049 (Rev 2/8/91) wp <br /> A Division of San Joaquin County Health Care Services <br />