Laserfiche WebLink
PUBLIC HEALTH SERVICESoP4�,N <br /> SAN JOAQUIN COUNTY F <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer ` <br /> P.O. Box 2009 • (1601 Fast Hazelton Avenue) •Stockton, California 95201 c,�i Fi 641 <br /> (209)468-3400 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ##iiiii/#####i##//##itiiii#it#it#►tt►t#t►k/iti/itit##►kk#►k►#//i#i/#i#//#►t#iiiiii►i►►►tt#tiitt►kkiitit►### <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: �Cr-16 e FD2D /ir 4/1'- /y19TF/LrAtS GC—:i&7-E12- <br /> FACILITY ADDRESS: 2100/ 16) C66i07 j /PD"10 L.00/GGFO/LD C-4- <br /> TANK ID #39 - :Z Tank Description: 64C-604.') I ESEL <br /> t##iiiii#i#iii##ktttiii##ttittitttttiiitttiikii##i►#i#k•ilii►ki#iitttikktt#t##ti######itiiittiiii#t►ttitt# <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: V 3 / W /V4 TGtY City /7140ES 70zip: <br /> Phone #: U 5Z T 9(053 Date Tank Removed: <br /> ii//iik#####ti###k#i#kt#iiiitiiitttiti#ikiiii#i##iiti►►#i►####i#kkii##iik###iti#ki##tktiii►titiiiiiiiii#iik <br /> SECTION 3 - to be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: S E A GO <br /> Address: el Vy, f'fITG y /C Ogle City: MODC-S 7'O Zip: 953.5/ <br /> Phone #: 7-09 ) 5-9 T 96 5 3 <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 /> iiiitik►#i#/iiikit►##i#ttitiiitit#iiitittiktikiit#iit#iii/k###i#kik##i###ii##kk###i###i#/ii//iii#tt##iii/## <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: L05y"'y 11ETAC-5 G'O�PPD2/�Tipiv <br /> Address: 6000 �//-h Sr Cit,: �IC�ln?dgi� Zip: 70,7,--1 <br /> Phone #: U -Z36 Deo 0 <br /> Date Tank Received: <br /> Signature: Title: <br /> t►►t#i#k#►###i#ti###i##k#tkttkitt#titfktii#itk#it###i##iii►i####i►###kkk##t►k#t#######iki##iiiiik##tt►i4►t <br /> Page 10 <br /> ER 23 049 (Rev 2/8/91) wp <br /> A Division of San Joaquin County Health Cue Services �� <br />