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4 PUBLIC JJEALTH SERVIJES <br />SAN) OAQ(;i\ Y <br />COUNT <br />M.P.H. <br />Kr ica Oiiker <br />P.Q. Box 3009 ® (1601 Fast H=clton.venue) ® Stockton. California 95201 <br />(209) 468-3400 <br />UNDERGROUND Ta NK DISPOSPTION TRACKLYG RECORD <br />s*a as ata*$*a a***** as a eel******laasts4 as*ease *see so**$ I ago a 1*0*411$ We a*t as as*so* aa *so a* e a as a a a aaa aaa a s on a a a so <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 recyrcling <br />facilir-1. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACZ-:TY NAME: <br />FACILITY ADDRESS: <br />TAMC ID #39 - <br />Tank Description: <br />*eases*etaeaassaeaasa*sasses$e•asaaaaea**asaeaasasaeaasaaes*aaeeaseaaasaeeaeaaaassaaaaaaaaaaasas*saeaaeasa <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor. <br />Address: <br />City: Zip: <br />Phone 70": ( - Date Tank Removed: <br />aeaaasmasaeesassaeassaaeesseeaaaaamaaaae**seeeaeeaaseemassasessaeessaa*tssaeaaeaaeaaaaaaaaeaa*aaaaateaeease <br />SECTION 3 - to be filled out by contractor 'decontaminating tank': <br />Tank Decontamination Contractor: <br />Address: <br />Phone ;#: (-� <br />City: <br />Zip: <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 />aaeaeaa•aaa*aeeseeeaseeaa*es*ea*aaa*esaeseeeaaaseeas*eeaeaaaaa*asease*smaaaeaeaaa•e*aaaaa*asasa•**aaeeaeata <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 />FaciIIry Name: <br />Address: <br />Phone #: <br />Date Tank Received: <br />Signature: <br />City: Zip: <br />Title: <br />taaatasasaeesaaseaseasasaeaesaasesesaeeaseaaastssasaaesaaaetesasaesasasaseeatatasaaeaasaaaasaeeaassaseaas• <br />Page 10 <br />EN 23 C49 tRev 2/9/91) wp y <br />A Dimmm of San Joaquin Cuuray Health C.se kmecs <br />