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PUBLI HEALTH SER ICES �0,1-� .�o .G SAN JOAQUIN COUNTY r. A\ 2 JOGI KHANNA M.D..M.P.H. Health Officer • �. . P.O. Box 2009 • (1601 East Hazelton Avenue) 0 Stockton, California 95201 (209) 468-3400 UNDERGROUND TANK DISPOSPTION TRACKING RECORD SECTION 1 -Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: A R Lo [^A G(L l 71/ t-" 20 7 G FACILITY ADDRESS: too BAST I-E TTLEWIA Q L AQ E LO D r CA TANK ID #39- Tank Description: 10 1000 G.AL - SECTION 2 -To be filled out by tank removal contractor: Tank Removal Contractor: Go I—PEN UJ 65T 4 U I UM2-S Address- P 0. 11,50X I23(p City: BRENTWODa Zip: 84513 Phone #: 4( 15 ) 634- IQq e Date Tank Removed: ##;;##;;;#ilii#itis#f tiYiiiiiiisif#iii#f#til#ii##iiiltii;iiiittt#!i#iifi##!i#lit;tltft##li##f#iiiiitl#ii##i SECTION 3 - to be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: ac)L J&-�j u16Sr IaUI LDE R-S Address: R 0. BOX 12,3G City.Me7KTW 00fl Zip: '2451-6 Phone #: i s (o 34 19114b Authorized representative of contractor certified by signing below that the tank has been decontaminated in an approved manner as required by the State Department of Health Services. Signature: Title: SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: H + H S l-F I P GeELV KF, Address: 220 GHI&IA E3p,5W City:5RIJ FRAQC5C0 Zip: 9410-7 Phone #: c 41 s ) 53 +b - Date Tank Received: Signature: Title: Page 10 EH 23 049 (Rev 2/8/91) wp A Division of San Joaquin County Health Care Services