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SER ICES <br /> PUBLI HEALTH <br /> SAN JOAQLIN COUNTY A\ <br /> JOGI KHANNA M.D.M.P H <br /> Health Officer • c P <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 4 e F 6,a <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ++++:++:++l+li+titaaiafif lis l:stiff+ftaa==alalia•its tilt aiitiiiialalia:fittif itff is aif li:,fa:.::ii+:+::ii+: <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 g Lo I^A G(L l Ty 4 20 7<a <br /> FACILITY ADDRESS: b 0O r.-AST V-6 TTL-6MA Q L.AQ E LO D i` CA <br /> TANK ID #39 - 3 Tank Description: 4,00c) G A 1, <br /> s:ssas:ssassisasssssasssassisssisssissssssssississssasisissisiissssssssssssiisssisssssssssfssassssissasssa <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor. Gc>L-PQJ WESY 4UIc-dERs <br /> Address: P o 1,50>4 1�3� City. BReNT1nI0av Zip: X4513 <br /> Phone #: ( 415 /034- IQq b Date Tank Removed: <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank': <br /> Tank Decontamination Contractor. &ot.De-�1 W6Sr @UI LC)E V-5 <br /> Address: R O. 50>4 123 City-JWC-WTW0Q9 Zip: g4513 <br /> Phone #: OF 634- Mb <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 /> iiatt tiifffttsifiif tttttiitiitti til:fiatitttiitiitaiiitifaifiifliaitatit ii itiiiittfifaf iif tiitif itiifif tf i+ <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: H k H 5 4I P Se V-V KS <br /> Address: -�2 0 GH Ki A DA ,W City:SP Q FRAU C(5co Zip: 9410-7 <br /> Phone #: ( 415 <br /> Date Tank Received: <br /> Signature: Title: <br /> sssssial+::::::lass:assfssfssssassssassssasssssissssisssassssssssssisssissfssssssssfssssssssssslassss+sass <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) wP <br /> A Division of Sun Joaquin County Health Care Services �> <br />