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APR 0 9 1993 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ...••..•.••<•••.•.r••••r••••••rr•••y• •••.••....• ...•..••••••••••••••N•••••••••••••••••••r•••••••r•••..• <br /> sl:t:l'ION t - Public Health Services TVIWking Sheet will accompany each tank afted with its site Identification number. <br /> The 'Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br /> Iccycling facility. The permit holder Is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: Hendrix & Sons Trucking', Inc. _-- <br /> FACILITY ADDRESS: 3730 Munford Avenue, Stockton, CA 95215 —_ <br /> TANK ID #39 - Tank Description: <br /> 9LC71'10N 2 - To be filled out by to k removal contractor. <br /> Tank 12::moval Contractor SToc�c—ro ya ` -cV ICF_ <br /> Address: `?SZ-y il/c- 0 ,yc43-6 f�',-n City: S 'Tnc c ro-J <br /> Date Tank Removed: <br /> .............•.•.•...•••...•.••••.••••.••••••••.•••••••••••••••••••••••••••••.•.•••••.•....•..•....:....... <br /> s13L l'ION 3 - To be filled out by contractor 'decontaminate taak': <br /> 'Tank Decontamination Contractor. Tcc'G-cotes E�ltc� <br /> Address:- 2(� /�tb �,tJ[o-.t� Clty•c -Y.t� Zip: Z� <br /> Phone #: ---- <br /> Authorized epr en contractor ceorad*ifying through signature below that the tank has been decontaminated In an <br /> upprovrnl in e as Cal qA. <br /> Siguawre; — <br /> Title:. �-�� <br /> SI.CI'ION 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: r Al Z-->Pts- ( -- <br /> Address: I S��li� f�� f�RDe�,b City. 1� (C�-r — Zip: <br /> CZ--O—C—() ---. <br /> Dalc 'Tallk Receiv ---.. <br /> Slguatnre, r Tile: _--- <br /> ,......• ••• •••1••N•.J•.H•�• •H.N•IH.•IH.•H.H•••J••••.•H•..••H•H•Hr•.••.1.•1••.•...•.. <br /> to 23 049 (Revised 7-10.92) Pepe 10 <br />