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SER CES ,oPa�tN �o <br /> PUBLI HEALTH <br /> SAN JOAQUIN COUNTY = Z <br /> JOGI KHANNA M.D..M.P H <br /> Heald Officer <br /> P.O. Box 2009 0 (1601 East Hazelton Avenue) <br /> • Stockton, California 95201 <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACIQNG RECORD <br /> tfff if iiifftfff itf iffafifitfiiitiffffiif ittitttfiti tttttttfttiiittt tiiifiiiitttti it titf iiiiiiitifiitiia iffi <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 P,Go [=A G l L t 4 20 6 <br /> FACILITY ADDRESS: �b oO BAST 1Z TT Le MA Q LAID E LO p r CA <br /> TANK ID #39 - 4 Tank Description: 4 ,00c) G.ALSECTION 2 -To be filled out by tank removal contractor. <br /> Tank Removal Contractor: G o LP E1J W EST 5U I L E R S <br /> Address: f' O G30X I�-3 City: 51zew-wODp Zip: q491'-2, <br /> Phone #: 415 ) 634— 1590, Date Tank Removed: <br /> SECTION 3 - to be filled out by contractor 'decontaminating tank": <br /> Tank Decontamination Contractor: 6 oLDe-l ] W EST PO I L'2E R-5 <br /> Address: R O. E50X 2-3(0 City:BRefJTUJ009 Zip: g45(3 <br /> Phone #: 44(5- 634— (9 '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: <br /> Title: <br /> iitttif flit ittiifftittt titfftttttttii tftf itittf itttiitf if iiitittititiitif itiiif tffiti of tiitifftittffff if tt <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 S H{P V{GE <br /> Address: 'l20 GH1Q]A DAA {tJ City 5pjw FRAgC(5(-o Zip: 94l0� <br /> Phone #: c 415 53 - 4e3157 <br /> Date Tank Received: <br /> Title: <br /> Signature: <br /> sssstitsssfstststitsssssssfsststssfssssatststsssssssstsssssssssssssttasssssststttfttssstssstat•sssssfrssts <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) up <br /> A Division of San Joaquin County Htalth Carc Scrviccs �> <br />