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r � U 11V <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY 2` <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer ;P <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) •Stockton,California 95201 4 !i=o R a <br /> (209)468.3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 -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: I ' -r-, <br /> FACILITY ADDRESS: 2QD Z All, &11 L.5o 1V cl,4 r'/ <br /> TANK ID #39 - 1 3 0 a - © I Tank Description: 120610 19-4Z4/_X/ <br /> SECTION 2 - To be filled out by tank remov4l��contractor: <br /> Tank Removal Contractor: SS <br /> Address: _ 4�3/ &J, 1��72� City: olez?ESZQ Zip: 9S35-1 <br /> Phone #: 5-3 Date Tank Removed: <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: ® /� <br /> Address: 7 � ?-CH f")Oifp City:1�`�OS54-0 Zip: <br /> Phone <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: �OZA 4 Title: <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: /hE7�L 5 <br /> Address: 6&�,9 4Zf 4 f-77 City: �LIjWOI-D Zip: Q� 3fO'y <br /> Phone #: ( <br /> Date Tank Received: <br /> Signature: Title: <br /> wws##sw#s##ss4s###r##########44s###*4##s#4ss########s4#4*################4###4#####*##**#####**#####444st# <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) wp <br /> A Division of Sun Joaquin County Health Care Services <br />