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PUBr ,C HEALTH SE"VICE <br /> SAN JOAQUIN COUNTYs� <br /> JOGI KHANNA M.D.,M.P.H. <br /> x <br /> Health Officer <br /> P.O.Bax 2009• (1601 Fast Hazelton Avenue) •Stockton,California 95201 �4 t i F b R <br /> (209)468.3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> rri#ii#rtrts#wi#rti##Ytrt!!#YitYiirtrti##Yiiiiiii#rtiiwtttirtrtrt#1rirtiti#rtrtrt#rttiiirtirtrtsriiiiirtrtws##ttiiYrtrtssriiiiYst <br /> SECTION I -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 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 returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANK ID #39- — Q 1 Tank Description: <br /> !r#rwtiiiiiYYrtrt#itiYttitiiiilYiYrt!liitiiiiiYYi#!liittiiiiYY#i!i#1tiiiilrtrtrtrtrt*wYYitiiiiYYrtti#Yitiiiilrtrt*#!# <br /> SECTION 2 -To be filled out by tank remova�ll contractor: <br /> Tank Removal Contractor: S65 2 <br /> Address: �3/ _� f/97Gff /1-0.¢D _...�City: 01-0,0E3-ZU Zip: <br /> Phone #: 2�I .�'-Zzjkl- 9(y�3 Date Tank Removed: <br /> i!#!rt!!!lrrrritttisiiiYY#rtirtrtrt!!!#Y#iriitititrtiYrtrtrt#Y!lsill!wriiiiiiiiYYYrt#rtrtissililrirt#iiti##YsrtrtYrtrtiiliir <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank": <br /> Tank Decontamination Contractor: 6a <br /> Address: f3� �,� 4�re- f &P ...., CityAMS-qi-9 Zip: 9S3S"/ <br /> Phone #: O . SZ 963 <br /> Authorized representative of contractor certified by signing below that the tank has been decontaminated in an approved <br /> manner as required by the State Department of Health Services. <br /> Signature: Title: Yi <br /> i*iii!lYiiYYY#rtrtrtrt#irtrtrt##rt!##srtrtrts##rtrt rr riiiriiiiiiiiiiliiyPiittrtrt##irtsrtw###rts irtsiii!#rtrwiw wiiwrrrrwriiiiis <br /> SECTION 4 -To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or pipinQ- <br /> Facility Name: CAL rn&L <br /> Address: 42.4 S._ T R G N E R City: T U R.L O-C K._ Zip: 95380 <br /> Phone #: ( 2 0 9J ) 6 6 8-9 3 7 8 <br /> Date Tank Received: Z 7 <br /> Signature: 44ZTI; 01WTitle: i-- <br /> Page <br /> Page 10 <br /> EK 23 049 (Rev 2/8191) wp <br /> A Division of Sal Joaquin County Health Cue Semccs <br />