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raefixed <br /> UM)MnZG ND TAMC DISPOSITION 'TRACKING RECORD <br /> eaChtank <br /> San JoagNln Locml Health District's Tracking sheet will accompany with ltO Mite identification number. The Tracking sheet 19 to be returned to San <br /> al Or <br /> Joaquin Local health District within 30 days Of acceptance of4the tank by la responn�lb_1e recycling <br /> o-S— <br /> recycling facility. ZA holder of the-i3ersit—vith <br /> onattring that this form 18 c(MII[l�wt-wA atr7 retL _1._ <br /> FACILITY NMWI Crrn t. -SIL C—IOLt �� C o«A �c` t C1�0.4sn <br /> FACILITY ADORE S1 zrz?Oc> C. <br /> TANK ID 139- <br /> AARAAARARARRfRAR}ARARARAAA}RRRf/1AAf11RRAARARAAAAARAAARARRARAARRRRRAAf1Af1ARARRRARRR*RA***RRARR <br /> SRC1'ION - 2 - To be filled out by tank removal contractor! <br /> Tank Reowal contractort STUJ:!(--ca,1 <br /> Addresst n1�c•O <br /> PhoneA! <br /> Telephoner (-1 1 C���� — b'�33 Date Tank Removed: <br /> Telephone! }ARAAfItfIRAAf1ARRRAAAf1ARRRARAAARARARAARRRRARARAARARRR*RARAAAARARARAR*R*ARRRA*R*RR <br /> MOC1'ION 3 -To be filled out by contractor "decontaminating tank": <br /> TAnk Decbntawlnatlbn" Contractor! <br /> Addreast �7v-�- o tf- IJLY/3 zip: <br /> Kw iA Wv0A o CA Phonel �'-- <br /> Authorlu_d represshtative of contractor certifies by signing below that the tank has been <br /> decontaminated in an apptoved manner as nay be regulated by Department of Health Services. <br /> SICNATIIRF. AND TITLE <br /> AARRRRAARRRRRRARARRAAAAAtRARRRRRAARRAARRRARRRAARARAAARAARAR*RAARARRAARRAARRRAARA*AA*A*RAA*R <br /> Sgt!TION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Addreast Zip$ <br /> PhoneA: <br /> blue Tank Recelvedt <br /> ACIINORIZED SI(NATURE AND TITLE <br /> -�'�' ' RR��RAAAAtRRRARR}ARRRtAARRRRARRARRRRRARRRRRRARAARAAARR}A*RRARRARRRRRARRRARRRA*RRARR*A*ARR*R <br /> sN 2i o�9 ltiee <br /> NAILING IN811WtION9t FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> _ ATTN! I*MGtOUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> t <br /> STOCKTON, CA 95202 <br />