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0 <br />PUBLIC HEALTH SERVICES <br />oA®...�.. <br />SAN JOAQUIN COUNTY <br />"+ <br />G <br />JOG KHANNA u.D., M.P.H. <br />�'•. <br />Hezith Officer <br />P.O. Box 2009 a (1601 East Hazelton Avenue) a Stockton, California 95201 <br />(209) 468-3400 <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />•seetelaaaeeasltaaaeaeeseeaegeagaeseaaeqeapeaeaaaaqespaqaaeeaqqtatapqapteaeepaaataatqeepaeataqeqpaqqqaaeaee <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: NAVAL COMMUN ICA -rIM5 5-r-)a-r"ion/ <br />FACILITY ADDRESS: C OU(q14 -+' READy r'5LA-vD 5rocr-r0n/ <br />TANK ID #39 - ' 9Z �' /7' Tank Description: 1i, 000 (a 1107) Lead1e / Vj1 %e°.ttC% 6501,1 <br />teat:.aeeasses°eeaeaaeepgseaaptaeaaaaaaeaeegeaqtpqeaaeqsaeeaasqqeaeeqeaeaasaeaqtqaaeaepeqeqqeqpaseeeseteat <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Riedel Environmental Services, Inc. <br />Address: 4138 Lakeside Drive City: Richmond <br />Phone r, ( S1 )_ 222_7810 Date Tank Removed: <br />Zip: 94806 <br />♦Eeeee!ltteelf eattigeaeppeaetegqtete!!egategetaaqtpggeee6eaqeeptqqeaqatqqaaqaqaqae egtaatetgeatapqqqa tet ante <br />SECTION 3 - to be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: Ri f�-tet Euld rnnmun+• t <br />Address: 4138 Lakeside Drive City: Richmond Zip: <br />Phone #: ( S1 C ) 222-781 n <br />94806 <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 />eaeaesaeespatgtpgqetsaeseqeqeaseqppaaaqeetapaqeaaetqqaeaqeqaaettetaaaqeqteetaaaaeaatteeaeeaasateaeeseaeataa <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: Oscar E. Eri rkgnn _ Tnr _ <br />Address: 255 Parr Blvri. City: <br />Phone W.:5( 10 l 235-1393 <br />Date Tank Received: <br />Richmond <br />Zip: <br />94801 <br />Signature: Title: <br />eeseseesseeseegappeegaeeqspaesqaqesepqaaaeaveeetaeeaeaeseaeeepaeetteaeeteqeeeqptetqeaqeeteeetteaaeqeaapaqa <br />Page 10 REN <br />EN 23 049 (Rev 2/8/91) up <br />