Laserfiche WebLink
PUBOC HEALTH SEMMES <br /> SAN JOAQUIN COUNTY <br /> N: •. a <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Office( • �4,. (P" <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 oad <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> 44t#t#ttt##ltt4##iii#lftfi4#ti###i##Yr##!R##4tttRr#ftt#4RtttY4flt##ifit44ltri4Rti##!!r###tr#4liti##itiYst#tt <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: Commercial Transfer Inc. <br /> FACILITY ADDRESS: c� 1651 Louise Ave Lathrop C3 95330 <br /> TANK ID #39 - lb�D -(0 ) Tank Description: <br /> EE10,000 kpal.' di��e��s��ej(l fuel <br /> SECTION 2 - To be Filled out by tank removal contractor: <br /> Tank Removal Contractor: Jim Thorpe Oil/ Rich-Mart Construction <br /> Address: 351 N. Beckman Rd./P.O. Bx.357 City: Lodi,CCa. Zip: 95241-0357 <br /> Phone #: (209 J 368-6175 Date Tank Removed: ,�/ / 3 <br /> #Rtt4!!tt#R4lY##itt##!ft#t##!i#t44#t#it4lR##44!##R!!#fYR##ltYi#!#rY###iY###!#fi4lRR##!!i##lf Y4###!i##ilRt#!f <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Jim Thorpe Oil, Inc./Rich-Mart Construction <br /> Address: 351 N. Beckman Rd./ P.O. Bx.357 City: Lodi, Ca. Zip:95241-0357 <br /> Phone #: 2( 09 ) 368-6175 <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: vM.A.t. Title: Contractor <br /> #4tlt#ft!##RRRtr#4ttr###!tt##l4i Y444Yrtt4ltfiY4t!#tttt##fftr#litt#R#tR###it####!#444iRr4#t##tRt#4#444Y#t#itY <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: Owner to retain tank <br /> Address: City: Zip: <br /> Phone #: (� <br /> Date Tank Received: 6 <br /> l <br /> Signature: / - /Z ' �(3 Title: <br /> #t4Rlt#r!R fi44tt#4#!##Tt4R##rRit##4#itt#t#3##Rr##!#tr4lt#i Y444Rt###4#444ttYt#4#####!t!##t###!###!!###!!#YR <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) up <br /> A Division of San Joaquin County Health C=Services �� <br />