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PUBLIG*HEALTH SERY S <br />aA * AQU.*COUNT Y <br />JOG K''H.kN .a `l.D.. `I.P.H. <br />' Kr»ice Oiiicec <br />P.O. Box 3009 a (1601 East Hazelton Avenue) • Stockton. California 95201 `\ <br />(209) $68.3+00 >. a <br />UNDERGROUND TA,NX DISPOSITION TRACMG RECORB �*ffi <br />�t <br />MAY 12 1992 <br />aeasass a Saaaafaae as aase•as s as Gass aeaaGoa aeeaa*aesees soa•aalalisa ta.#Sao aaassaasea as•s!!6lere•lt eiea6elallaas <br />SECTION 1- Public Health Services Tracking Sheet will accompany each tank affixed with J[fhe <br />Tracdn; Sheet is to be returned to Public Health Services within 30 laws of acceptance of the toecjcling <br />facWcj-. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACZ-/TY NAN <br />FACILITY ADD <br />TAN'S{ ID #39 - <br />lq <br />sassesessGasate <br />SECTION 2 - To be d1led out by tank removal contractor. <br />Tank Removal Contractor. <br />Address: <br />City. <br />Phone ?"r: (,� Date Tank Removed: <br />Zip: <br />ssaeeseeaaessesaaGaseasesaGaaaa ssaesesaaesaaasaasassaG#asssssassssaessassseaas6esea!lsaaasa!l6saaeasaeassa <br />SECTION 3 - to be filled out by contractor <br />Tank Decontamination Contractor: <br />Address: <br />Phone #- <br />0 <br />City: <br />Authorized rept tiv contractor ce d by signing below that the tank has been decontaminated in as approved <br />manner ed b e St to Department f Health Services. <br />Signatur : Title:, <br />esascseassaa• asa#eesa••saGsleal6ee6eaevaaa•Mslsali6asaasistaeaeaaaGGeeaas!!!!!!!!!!!!!#!!#!!!##•eieae##• <br />SECTION 4 - be sign and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Fac: iry Name: K I <br />Phone #: 3 <br />Date Tank Recei . _-v- f 1 I - `1 <br />1 <br />Signature: Title: <br />tasesaeasaeaa seatea •6166• s80saess•sessass6s8ea6e448taaseaaese6aeasa•sasaaa6rasaass6esearas6saessee <br />Page 10 <br />EH 23 C49 (Rev 2/9/91) WP <br />A Diwrm of San Joaquin Caunev HcWth Cite Scmccs �.% <br />