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S <br /> PUBL HEALTH SERVICES <br /> SAN JOAQUIN COUNTY r <br /> JOGI KHANNA M.D.,M.P.H. H: <br /> Health Officer <br /> P.O. Box 2009 (1601 East Hazelton Avenue) # Stockton,California 95201 <br /> (209) 468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 isocompleted and returned. <br /> FACILITY NAME: 011'aqe., <br /> FACILITY ADDRESS: la6L& Elnb <br /> TANK ID #39 - I D I TJ Tank Descriptio . i/D1 ODO qct/ &U l_T� <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 04CA& 3:-" CL <br /> Address: � �'. "��, 1101 0 City: yo6gid vi Zip: ��ZQ <br /> Phone #: (2D9 ) 9Y -( 11Y Date Tank Removed: <br /> SECTION 3 - to be filled out by contractor " econtaminating tank": <br /> Tank Decontamination Contractor: .� �� tL �� ,'��ry► cAL C <br /> Address: ov 3,G- 702'FCp-tr. DR- City: S+o 4ekZip: q n <br /> tfAutPhone #: c�o9 > � !y it,- <br /> Authorized <br /> horized 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: W © Title: n;neCy_p/t,..� r <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> acceptin tank and/or piping. �/ <br /> Facility Name: ✓^� cal r►�s' e'_ ��'_ .�C1 C 'r'yt 0'V e_"*C.► <br /> Address: ,��a 2!5eui Ave- City: S ate Zip: 951a, 3 <br /> Phone #: ( J +- <br /> Date Tank Received: <br /> Signature: Title: <br /> Page 10 <br /> EH 23 049 (Rev 2/8/91) up <br /> A Division of San Joaquin County Health Care Services 40 <br />