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SAN aoAQLJIN r,OCAL HM T.TH DISTE22CT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br />affixed with its site identification number. The Tracking Sheet is to be returned to San <br />Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br />recycling facility. The holder of th-e--Dermit with nnmlr, moi,... : <br />FACILITY NAME <br />FACILITY ADDRESS: / 7 6 6.5 5 <br />TANK ID 039--/S 0 <br />SECTION - 2 - To be filled out by tank removal contractor: DEC 12 1980 <br />Tank Removal Contractor: <br />Address: <br />Telephone: ( ) Date Tank Removed:2 <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: % RL <br />Address: <br />z i S'� 3 /3 <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved manner as may be regulated by Department of Health Services. <br />� / <br />#**#***x**#t***********************t***GN***TUxrEcWAND <br />#**TITLE <br />*t*****W*******W*#********W*#x****xk* <br />SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Name_ Alu117e5 <br />.w.. <br />Ell 23 049 019 1 <br />11/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROM M <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />