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41 7rZ <br /> SAN aOAQT TSN '.LOCJ2aT. HEALTH 0T SIRS CT' <br /> UNDERGROUND TANK DISPOSITION TRACKING RECrk <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 the permit with number noted below is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: Lae qq+ d �✓�K�y rj co, nn �T <br /> FACILITY ADDRESS: �L�7 / ckkvy7 <br /> --v Qv1 I-OrAl <br /> TANK ID #39- <br /> SECTION - 2---To-be-filled out by// tank removal contractor: <br /> Tank Removal Contractor: lCJeSteyin v4-ie of Se y%,-, T 3 <br /> Address: A735 %Ee Pec- j)ie z�, 5 ekk)m Zip: 9S2ds <br /> Phone#: .2-p9 <br /> ' Telephone: ( ) Date Tank Removed: <br /> ,.SECTION 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination" Contractor: % We4c v- Se ✓✓,cam , <br /> •Address: .1735 Ar z3,1, ilf Zip: 52� <br /> Phone# : fi <br /> s <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved <br /> manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> *k************X•***** <br /> �S <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank . <br /> Facility Name -r1AA1Q-LC <br /> Address: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: <br /> � t <br /> AUTHORIZED SIGNATURE AND TITLE y <br /> SH 23 049 12/88 <br /> HAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> A4TN: UNDERGROUND TANK PROGRAM {} <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br /> : i <br /> : i <br />