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� - PUBLIC HEALTH SERVICES <br /> SAL\'JOAgUI,\,'COUN 1�Y r <br /> JOG[ :::�AvNA Vii.D.M.P.H. I x <br /> Hn;rh 0ftS[Cr y <br /> P.O. Sox 2009 • (1601 East Hazelton Ay muc) • Stock-ion- Czuornia 95201 =a a�'• <br /> (209) 468-3400 <br /> UNDERGROUND T,IYK DISPOSITION TRACKIPIG RECORD <br /> .s..#.•"......••..i...•....Rif......3 i 1.i....... <br /> #i........•.......... <br /> ...•...f.... <br /> 1•#.....l l.........•.. <br /> SFC i lOiN 1 - Public Health Services Tracking Sheet will ac:.ompanv each tank affixed with iLs site identification number. Tae <br /> Tiac:� n-c; Sheet is to be returned to Public Health Services within 30 dans of acceptance of the tank by the disposal or recvc.in; <br /> facility. The permit holder is responsible for ensuring that this form is completed and re:urned- <br /> FACIL FIv. NAME. PG&E <br /> FACILFY .A.DDRESS: 4040 West Lane , Stockton , CA . <br /> Tr,N-K ID m39 - j � f D* Tank Description: 2 = 000 Gallon Diesel <br /> ...........................................f.........}i................................ ......... ...... ., .. <br /> S CTION ? - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: FHEMCO <br /> Address: PO Box 88 City: Tulare Zip: <br /> 93275 <br /> phone m: 2( 09 ) 688-2977 Date Tank Removed: <br /> 4 <br /> .........................................##............................................................... <br /> SECTION 3 - to be filled out by contractor *decontaminating tank": <br /> Ta: Deco;ac2mi;,at:cn Cznt:ac:or: Erickson , Inc . <br /> Address: 351 W. Cromwell Av. , # 103 Cipr. Fresno Zio: 93729 <br /> Pone #: { 20P 432 -9005 <br /> authorized representative of contractor certified by signing below that the tank has been deconmms,^ated in an aooroved <br /> manner as required by the State Department of Health Services. <br /> Signature: Title: <br /> .•.........f.......... .............. <br /> SFCTiON - To be signed and dated by an authorized representative of the treatment, stora;e, or disposal faclirf <br /> acc,pting tank and/or piping. <br /> Facility Name: rickson . <br /> Address: 13738 Slover Av Fontana 92335 <br /> City. Zip: <br /> Phone T: { 714 355-5601 <br /> Date Tani, Received: <br /> lature: <br /> Title: <br /> Page '0 <br /> =w 23 049 (�ev 2/3/91) wn OMS'On of tan Jomgwn COr.Hr-Ui C_rr is- c-i <br /> \� <br />