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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY =' z <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer % a <br /> P.O. Bax 2009 a (1601 East Hazelton Avenue) 0 Stockton, California 95201 <br /> �'i CIFpR�`P <br /> (209)468.3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> is;s!##:#aiYYriiii;rill;;;;};as;ls+sYrliraasea Yr:riYYixi#ls Yr Yrarir Yi YsiYraarraiiaisr+++t++!!!!•##;itisirfa <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 rec.Wling <br /> facility. The permit holder is responsible for ensuring that this form is completed and returned! <br /> FACILITY NAME: 0-A rwcr% 41 a cto <br /> FACILITY ADDRESS: AROIr E# Marck Lone. 15r"ApL C <br /> — <br /> t <br /> TANK ID #39 - J Tank Description: Gtr4jP_ �.lall k-usp6z•,5 <br /> li#}!+#+r#r!Y#}Yt;kitkt;}illi Rtikffiii;ii}i#}##ii}iiiift;;t;;Ykiititt}iiYit Yi#kY#i#i}!!!;##i}#}iti;}i;iitr <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: E'QCo C�..�So CAr AT0 C1)t-I.nr�— 9=RnLIRll1--Iy <br /> Address: 9 .0 . City: �rAr� WX, tC A G'0S7-7 <br /> Phone #: Date Tank Removed: <br /> i!#it#ilttYra#riirrYY;iiif iiitri#}ki;};##}#}+}flit;ii;iiiitiYYirirrYiYirtattf!!+##t;}}#;}}#!};;a!#+Y;#};;#R <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: 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: Title: <br /> }i};#+tittitiiYrii;;}R}k;;##!}aa#triiitaf}ffltli;itaitik;tifflila};;;}f}it;+t}i}#}i}}+}t#+l1+Yltarriii Yr Yat <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: City: Zip: <br /> Phone #: ( <br /> Date Tank Received: <br /> Signature: Title: <br /> iiaar Yrarrr!laa+taiai;a#i##++arrraiaaalrtl#;##iasiia Y#a;oro Yasa#;##+a+sattt•r+++ataa!#t;taii:ir�atat rataaa <br /> Page 10 <br /> EX 23 049 (Rev 2/8/91) up <br /> A Division of San Joaquin Cowry Health Care Smitts <br />