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SAN J O m <br /> . AQUIIV LOCAL FiF=ar.mH AI5"I�2IG"Z' <br /> LNDERMC BdD TANK DIspOSITION TRACKING RWORD <br /> *******�>♦fiRfik**��***!!!!t!!!lYttltttftttftRRfRRRR*RRRRAA*MAAAAAAAAIAAAAAAfAR•AAMAAk#k**R#xt'R <br /> SEL' ON 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. Permi _ <br /> Xith number <br /> ensuring that this o m is r.+uu�nle e' a r *nrn V <br /> FACILITY NAM <br /> r( a� <br /> FACILITY ADDRESS: <br /> TANK ID #39- �g ® "' " <br /> �L.dSC� ® PERMII f SER7Zo <br /> ttttR**k***R*Rk*YR****#t#tRt**xkkA**R**R*RAxRRt*!R*t*!RR*RRk!*#tltR*t#!RR*lRtR*kRtRRk***k*R <br /> SWrION - 2 - To be filled out by tank removal contractors <br /> Tank Removal Contractors_ <br /> Address, zip, <br /> .phone M: -SS3S- <br /> Telephone; ( ) [kite Tank Removed: <br /> #*xAAAA#Rkt****kR!ltRA#AA**RxR*t!#xR#*#ARARxrrr*rr#*R*ARRRrttt#t <br /> _,... .. .... LLa.w vu4 ✓r ..V..4Lu,/L�V/L� "UGLVI�WINllkf l.l.n�J LanK-afirtrt�filfaaeaa�nrtaealtrttrf r,tt <br /> Tank Decontamination" Contractor: _{� Q(j r n . �IL ) �, 4 — <br /> Address s _e-)o � <br /> PhoneM: ,girt <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 /> RR*AR*#**RkRttR*MkRRRRkRtrkt*RRk#**RR*GNARnRRAAND <br /> *kRTITLE <br /> tlRRRRARttttt*tR*RR#At!ltRRlAlR*Rtt# <br /> SECPION 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 /> Address; <br /> Zip: <br /> PhoneM: <br /> Date Tank Receivedt <br /> t - <br /> kRrR*RRRRR#RA*r**RRRR#RR#R***#k*#kW*ARftV SIGNATIREE AND TITLE <br /> EH 23 019 12/88 <br /> HAILING INSML'CPIONst FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAG8. . <br /> SAN JOAOUIN LOCAL HEALTH DISTRICP <br /> ATM: UNDERGROUND TANK PROGRM <br /> P. 0. . BOX 2009 <br /> s . STOCXTDNj, CA 95202 - <br /> TOTAL P.'I1 t' <br />