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PPUBLI HEALTH SER CES 'T <br /> �o <br /> G <br /> SAN)OAQUIN COUNTY z <br /> )OGI KHANNA M.D..M.P-1-1 � y� <br /> HealdS Officer q ;P <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 <br /> ��FOR <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSMON TRACKING RECORD <br /> ssssssssifssssisssfsssfssssssssfsstsfsstitftssfssitfsfssfssfsfitftisisisffsfsfYssfffitffssssisfisstfsssstsf <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: A RC,o [=A G(L l -4, 2C)7(0 <br /> FACILITY ADDRESS: �boO V-E TTL6jNtAQ LAQE LOD CA <br /> TANK ID #39 - 2 Tank Description: 6 00o GAIL <br /> fsssfsssstsassffsisssfssasssssfstfssssssssssYsfiisssfsssstsitYssisYssitstssassisftssssfstssstsssfssssfssis <br /> SECTION 2 -To be filled out by tank removal contractor. <br /> Tank Removal Contractor: GoLpE1J WEST 5UII.VE(LS <br /> Address: P O CvO)1 12-3(0 City: 8I2E'urwoDp Zip: Q4 513 <br /> Phone #: ( 415 ) 6634' 15-Re Date Tank Removed: <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank": <br /> Tank Decontamination Contractor. 60l-D3 WES U1C.��R'S <br /> Address: P,O. BOX 1236 City:Melaw009 Zip: 94513 <br /> Phone #: l S 634- 19q b <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 /> tititt•Yfffiiftiit Yt of ifitititi Yiiit ttiiitif flit ittiYiYf itf itttfiiYYtiii iiftiftiiiif ifftitifff•itif iiitffi <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: I-f S Ft l Pse V(Ge, <br /> Address: 22 0 GH(til A 13Prs WCity 51k1.1 FRL�IJUSC� Zip: <br /> Phone #: ( 41 <br /> Date Tank Received: <br /> Title: <br /> Signature: <br /> ssfffsassssfsfssasssassssstsfsstsssssssssasfsssssssssssssssssssssisssssssssassssssssssfssssisfssssssffssss <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) uP <br /> A Division of San Jtnquin County Health Circ Scrviccs �> <br />