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PUBLIC HEALTH SERVICES <br /> SAN j0AQUHN C0UN i i' r. M <br /> JOGI K ANNA M.D.UR <br /> nc:;th Ofticcr Y <br /> P.O. Sox 2009 • (t 601 Ezsc Hzzc1con Avrnuc) • Stockton, Ca&orri 95 201 v�f��i a�'• <br /> (209) 468-3400 <br /> b-NDERGROUND TAINK DISPOSITION TRACKONI G RECORD <br /> •.r.!!.!.\..r*....*.•r.*!illrra\•..•*..**l..............•*..*.rwr..*..\#......——*...*..... <br /> SECTION I - Public Health Services Trac''king Sheet will ac:ompanv each tank affixed With its site identitication number., ; e <br /> Trac,cirt� Sheet is to be returned to Public Health Se s within 30 days o{ac eptance of the tank by the disposal or recycling <br /> facility. The permit holder is responsible for ensuring that this for is completed and re.urned. <br /> F.-kCI.LM, NA_v E: P G&E <br /> 17 C9_ITYADDRESS: 4040 West Lane o k <br /> TANK ID 39 - _ — 0 Tank Description: 5 000 Gallon <br /> Un I <br /> ...............................*.........................................\................................ <br /> SECTION 2 . To be :-lied out by tank removal contractor: <br /> Tank Removal Contractor: FHFMCO <br /> ,address: _ PO Box 88 City: Tulare <br /> Zip: 93275 <br /> hone ,: 2( 9 ) X88-2977 <br /> Dale Tank Remove,.d.: <br /> *.,.....ir.*........................■r.*.......*..........r................................................. <br /> SECTION 3 - to be filled out by contractor 'decontaminatin; tank': <br /> Ta-nk Decont2min3t:r,n C.7n[raC;Or: F r; r k <br /> Address: _351 W. Cromwell a • # Ing Circ: Zip: <br /> _ 93729 <br /> ?hG <br /> 729Phone #: 0 9 4 3 2- <br /> Authorized representative of contractor certified by signing bellow ;hat the tank has beets decontaminated in an approved <br /> manner as required by the State Department of Heal[,'t Szr•;c s. <br /> Signature: <br /> Title: <br /> !...*...•*!#...!f.#i**i i!i\..*•...•#i#i i*!\......#e#**#..!#..,.............Y!!••..........•..............•* <br /> SECTION - To be signed and dated by an authorized repre5entative of the treatment, storage, or disposal facility <br /> acc opting tank and/or piping. <br /> Faci[iry Name: Erickson , Inc . <br /> .address: 13738 Slover Av . Cir-1: Fontana Zio: <br /> 92335 <br /> Phone T: L_214) 355-5601 <br /> Date Tank Received: <br /> tature: Title: <br /> ?age ,0 <br /> _x 23 049 (Rev 2/8/97) +a <br /> 5 ns on or San jaacl cap qn HcJ 1 C_rc is v cca C ) <br />