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PUBLIC HEALTH SERVICES <br /> 5Ai\;JOAQUIN COUN-1 Y <br /> HANN M. <br /> ti-:ith Officer <br /> P.O. Sox 3009 • (1601 Fag Kizclton Avcnuc) • Stockton, C..alifornia 95301 <br /> (209) 468-3400 <br /> UNDERGROUND TAINK DISPOSITIO,ti TR.ACR'ING RECORD <br /> ■....tstsss..as.a..r sa.Y.ai asrera.eataa as Ya.....ra u.ss.t.a.r.r...ia....asr■ar-.....rrr........a.....a...r.. <br /> SECTION 1 - Public Health Services Trac!dng Sheet will accompany each tank affixed with its site identification number. The <br /> Tracing Sheet is to be returned to Public Health Services within 30 dans 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 /> F.�CILTI Y NAME: PG&E <br /> :ACILCIYADDRESS: 4040 West Lane , Stockton , California <br /> TANK ID #39 - �I_ j — Of Tank Description: 5 , 000 gallon Regular Gas <br /> ­ <br /> —C* <br /> a t a..i* <br /> i r, <br /> f t i s s t l t t ..a.......a........ <br /> SvCTTON 2 Ta be Filled out by tank removal contractor: <br /> Tank Removal Contractor: FHEMCO <br /> Address: PO Box 88 City: —Tu a r e Zip: <br /> �ltane ( <br /> 209 688-2977 <br /> Date Tank Removed: <br /> iii t t a.....a s J...........a............................. <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: 351 W Cr ='f I City: Fresno Zio: 93729 <br /> Phone m: ( 209j 432-9005 <br /> Authorized representative of contractor certified by signi.-ig 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 /> .sa.Y..s..YtsssisiirYtrs.ras..isiYYai i..a...........ra.a....a....................-...a...... ................ <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: _Er T e k,s o <br /> Address: 13738 Slover Av , City. FontanaZic: 92335 <br /> Phone #: 7 14 355-5601 <br /> Date Tank Received: <br /> lature: <br /> - Title: <br /> s.rrrt..s <br /> ....................................................,.... .....r............. . .... ....... ... ...... <br /> ?age 10 <br /> EX 23 049 (Rev 2/8/91) up <br /> A Dryu on of San fmcum C-L(enmti C_r- � f 7 <br />