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PUBUC HEALTH SERVICESrQ��N <br /> SAN fOAQU[N COUN—i Yz: <br /> fOGi:4,14A;1tiA 1i.0.. '.45.?.H. <br /> 1-iaitn Officer ~ <br /> ..C, .. <br /> P.O. Sox 2009 • (1601 Est f Iazclton Avrnuc) • Stockton. Calilornis 9520t <br /> (209) 468-3400 <br /> UNMERGROUND TAINK DISPOSITION TRACKLNG RECORD <br /> ........................•....................................•................................... <br /> S- 1< <br /> CON 1 - Public Health Servirzs Tracking Sheet will ac:ompanv each tank affixed wna <br /> with its site idetifiction number.`"I <br /> 1e <br /> Tmc.%dn- Sheet is to be returned to Public Health Services within 36 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 re.urned. <br /> F.ACLLI f iv -ME: PG&E <br /> ACU—= ADDRESS: 4040 West Lane Stocks n <br /> TANK ID .#39 - ( 3 7 Tank Description:l2 , 000 Gallon Un I eaded rag <br /> ................ <br /> .......■.a.....f...i.................i.....................••.a i a...............1............... <br /> S:-CYTON 2 - To be filled out by tank removal contractor: <br /> Tan;: Removal Contractor: FHEMCO <br /> address: PO Box 88 City: Tulare Zi 71: <br /> 9'3774 <br /> "gone T: (_ 688-2977 <br /> Date Tank Removed: <br /> ............................t...................t.......................................................... <br /> SECTION 3 - to be filled out by contractor `decontaminating tank": <br /> Tank Decontamination Contractor: Erickson , Inc . <br /> Address: 351 W. Cromwell Av . , ,x103 <br /> Cirv: Fresno Zip: 93729 <br /> 20 432-9005 <br /> P`one —J <br /> Authorized representative of contractor certified by signing below that [he tank has been decon[ar t: sated in an aapr;,ved <br /> manner as required by the State Department of Heaith Seres <br /> vic . <br /> Signature: <br /> Title: <br /> ................................■... ............................................................... ... <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or ;SDCsaj fac;l;r <br /> accepting, tank and/or piping,. <br /> Facili[v Name: E <br /> AddresS: 13738 Slaver Av . <br /> Cirr: Fontana Zi o: 92335 <br /> 1 355-5601 <br /> Date Tank Received: <br /> ta[ure: <br /> Title: <br /> Page 10 <br /> =H 23 049 (2ev 2/3/91) wp { <br /> A �)rvu.on of 3n)o�gwn Counry HcJc.1 C_tc ices \ <br />