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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - The San Joaquin Local Health District's Tracking eeW ` YS <br /> will accompany each tank affixed with its site identification number. <br /> The Tracking Sheet is to be returned to San Joaquin Local HealtyN�1'` <br /> District within 30 days of acceptance of the tank by disposal fir PV <br /> recycling facility. The holder of the permit with number noted above <br /> is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: ��t/ �� ./j '7E�'i�/ri1� TANK ID #39-/,&0 -1 <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: !�C0b00 (QFp <br /> Address: q)�) S . M2+^�Gtf� S� Phone # <br /> C,^ , CA Zip <br /> Date Tank Removed <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank "Decontamination" Contractor -5tj b013 F (j)TP <br /> Address _� A-M C/ Phone# <br /> &S I )p.J--e Zip <br /> Authorized representative of contractor certifies by signing <br /> below that th tank has bee decontaminated in an approved manner <br /> as may ere late by D tment of Health Services. <br /> t1il(L�P YIAC 1✓1 <br /> SINATURE AND TITLE <br /> SECTION 9 - To be filled out and signed by an authorized <br /> representative of the treatment, storage, or disposal facility <br /> accepting tank. I ,, <br /> Facility Name �—,-I ( 4-1r �V1 �V-- C W C. � <br /> Address � t� lnn sa ,,,-��Phone I — 4T <br /> Zip `2 Sa2C <br /> Date T ceived <br /> RUMORIZED SIGNATURE AND TITLE <br /> MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P.O. BOX 20091 5Tocklonl � CA c15201 <br />