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PUB.WC HEALTH SEWICES 4to�SAN JOAQUIN COUNTYJOG[ K14ANNA M.D., M.P.H. <br />Health OfficerP.O. Box 2009 • (1601 East Hazelton Avenue) a Stockton, California 95201kda <br />(209)468-3400 <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />................. ♦•......... •...... <br />•••♦••••••f•ff •fti••fill•.uf•a•f...•...a..au•aa••.afffaf •!••u•••!.••.. <br />Sr;CPION t - 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 dols of acceptance of the tank by the disposal or recycling <br />facility. 'i ne permit hn1dder is responsible for ensuring that this form It completed and returned. <br />FACILITY NAME: ( tun Fife C' A^^JPy-C AE -1 <br />— — <br />FACILITY ADDRESS:_ 3(e. ", +' A", At (I ad -- <br />TANK Il) #39 - 233 �I Tank Description: l tU ��cf� (�u\Oa✓(� ��1� �TE�t i 3(�1� <br />u•♦.....a♦a.••r•fr•u••.•r••r«Y•♦•••too N•ff••Nf•af••a••••••••••L•f••••1•H f+••fi•H•1•••-•••.•.u•••... <br />SECTION 2 - To he filled out by tank removal contractor: <br />Tank Removal Contractor: ? C VIe-tr---- <br />Address: se,? -)— Isle 1 UAI non !�r City:` C m✓ Zip: c—is�-'p0.'s. <br />Phone. #: (,,,�\I6) Date Tank Removed: <br />•.•....•..•••.•.••••u••r•••••«.>.•••s•stiafi HffH.f.Narafaf....NHSN NHurN •1•HfNH•«.kf••a••••••.• <br />SFCIION 3 - to be filled out by contractor "decontaminating lank': <br />Tank Decontamination Contractor: �ey aEafl l rl — <br />E;.,�: city: Zip: <br />--- <br />Phone #: (� ij �'; -a — l Jc�.� — <br />Authorized representative of contractor certified by Signing below that the tank has bees decontaminated In an approved <br />manner at required by the State Department of Health Services. <br />Signanuc: — Title: <br />•....>,.••••a•u/•••..a>..a••.•••.•a••••f1NMNflffYNHffaNfafiNlNNfai a4UfNH!lf NfN.lu•f Hl.••• <br />SECfION 4 - To be signed and dated by an nrdhorized tedtesentativa of the treatment, storage, or disposal facility <br />accepting tank and/or pg. <br />Facility Name:._L.\.G.� <br />City: kwk'Nt��_ Zip: <br />c� <br />� 5 <br />Date T'tulk Rccrioed: <br />;ignannc: Title: <br />.>Na•..•..•..•..•..........••..•••.•/•>•Yf••ffHUffNffffaf•afYHfff•f!f •f •ff Hff♦f•M•a•a••••. ••.r•.... <br />Page 10 <br />ER 6 6--; (Rev 2/8/91) wp <br />A Division of San Joaquin Count] Health Cate Services <br />