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ssssssss«ss«:sssss«s«sssssssssa«ssssssss•sss««ssss«ssssstssss««s«ssssatssssssatttsttssstss:sssssssssssssas: <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed 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 />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME: Lodi Memorial Hos2ital <br />FACILITY ADDRESS: 975 S. Fairmont Avenue, Lodi, CA 95240 <br />TANK ID #39 - Tank Description: 1-1,000 gallon tank <br />:sssss:ss:sssss«sssssssssssssss::sssss«ssss«ssssssssssssssss:sss«ssssssssss:ss«s«««::s�ssssstassss«:::sass: <br />Phone #: / ) Date Tank Rem March 15, 1993 <br />ss:ssssssssssssssssssss«ssssssssssssssssass:::::::sssss::ssssssss:ssssssssssssasssssssssssss:ssssssasssssss <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. y — '`/�` '�.- <br />Address • r ® S City: gip; <br />Phone #: <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />approved mann required by Cal EPA - <br />01 <br />«s««««:««««ss:::ssss«s:::s:ss:s«ssss:«:sssssssssssssttass«:sssss::::sssss«at««:s««ta««««ss««seas«s:ss«««««« <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: George L. Herbst <br />Address: 8 Mason Road City; Yerington, NV Zip: 89447 <br />Phone #: 7( 02 ) 463-2759 <br />Date Tank Received: March 22, 93 <br />Title: Owner <br />sssss:ssssssssssssssssssssssssssssssssssssassssssssss:ssssssssssssssssssssssssssss«assssttsssssss::sssss <br />EH 23 049 (Revised 7-10-92) Page 10 <br />