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PUBLIC HEALTH SERN-iCES <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> .......N�� <br /> P.O.Box 2009• (1601 East Efazc/ton Avenue) • sroclno4 iF California 95201 o a <br /> (209)4683400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> aaa»aasararrrrr••r,rr•art•r•rrarrras•rrrrrarr•♦rr•r•a•a•rrprraarrararrrgarrr♦p•••••rrrrrrarxraa•agrrw <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 its responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESSS: �! W , AIR i rf E ly D �Q EUGdi (ft/n P <br /> TANK ID #39 - f 6 6 --L52�?—Tank Description: (<jA(.GOA.) <br /> ••ar••rrarrrasrar•gtrprrrrrrrrrrrrrrrarrp••rrrrarras•raaawrrrrrq»rrarrgarasar••rrrrxr•aarrrrraarrq <br /> SECTION 2 - To be filled out by tank removal contractor: S��GO <br /> Tank Removal Contractor: <br /> Address: City: 1116D C-5T0 zip: 9.5 3 S l <br /> Phone #: ( 209 1 7 2 9 6 S� Date Tank Removed: <br /> •,rasa»rxarrrrrrrxrasaxaarq•r••xrrxarq•grrrxxrrra•rrrrrrrrrrararrrraararxaararra•xrxxaraaxsxaaarrrraaaa <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank': <br /> Tank Decontamination Contractor: 7C_/!7 <br /> Address: / /( 'E/!A IGF( b City: 0De570 zip: 9595 / <br /> Phone #: (Z(J 9 ) SZ 7 96 53 <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: r/ ���I c�^, Title:_��2��b�`�'�L <br /> VV <br /> •raaaaaarrrxrasa•••rrrrrras•sarrrrraaaarrrrraarxarrararra•rraaar«ars,araarxa»arrasaa»raxrraara,rrxxaar»r <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: <br /> Address: ��� �{�h ��/LC� City:&RofovD Zip: <br /> Phone #: 7( C//S 1 Z 3 O&�(� <br /> Date Tank Received: <br /> Signature: Title: <br /> ••,rxrrraaaarrrrxrrrr•rr,arraraaraarrxrrarrrrxrrrarrrraaarrrarrrrrarrrrrxarrrr»srrsr«rxxaraarr,rrraraarra <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) wp <br /> A DMmm of San)oa9Wn Courcy HcaHh Care Scry a V <br />