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UMMOUND TANK DISPOSITION TRACKING RE03RD <br /> *XkR!lt�xtR�X(t7tRRAt{tttttttlltittttllttifft#Y#k#RtIRRRRRMII#RAARAAAAAAAIAMAMRAAiy#**M##*R*XWX <br /> SDGTION 1 - The San Joaquin Local Health Districtfs 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. MIC holder of thi: <br /> V <br /> FACILITY NAl02t D <br /> FACILITY ADDRRSSi LTH <br /> TANK ID Y39-_Za <br /> °PERM, <br /> ttttRX*ktt**#*RkRt****#tXt#XXX*XkRX*R*Xt#*XRkRRkRtt#k*XXkR*kRtttkX#XXlklt**R**XXYRXXk******R <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Co <br /> '�ntractor: _}� �(�n r �l )/1 /! .� Lf) �� n � 1 d� <br /> Address; �f`,LQ (� a x'� �) , _Z&,,, �Sas7l Zip. <br /> Phonal: G,-Cv.S". 2-SS35 <br /> Telephonet ( ) Date Tank Removed: <br /> R RXfi YXRR*RX*RX**Xfi.YR**XRk*kR <br /> c �_.,... .. ... .... .... . ... RXXXtRRRRwRX*XXRtY.*XX#Y�kR***atg* .JtiRdnK-. <br /> Tank Decontamination" Contractor: 420f],rrni ( <br /> �f(I(f�fAAfiil$1i f(Tf 1111(S it l;tittiYz�t <br /> �j11 r1i� rl`l <br /> Address.: 7o?DD /.(��/0 ti � C� � �Z) Zips <br /> Phonel: 9Z - -S <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> doeontaminated in an approved mara*r 83 'ay be regulated by Department of Health Services'. <br /> SIGNATURE AND TITLE <br /> _,t k#RRRkt*tR*t#kR*RXRfiRkRkYkktRRXR*X**RtRYXXkfi#RfiRRRkRYXXkkRRRR*tttXXt#t***RXX*X*YX#kXk*X##f! <br /> ' SECPIGN 4 - To be filled out and signed- gned by an authorized represnetativa of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address; <br /> 21p: <br /> Phone#: <br /> Date Tank Recelvedt <br /> AVIIILUIZU) SIMATU?Z AND TITLE <br /> XR**#***#*t#R*X##**kX*RR*k**RXXXRR#*RRXkRRRkRRXX#tRR**!*RXkfiXXXXX*XtX##tRk*XtYtXXY**X!*XRXX <br /> EH 23 019 12188 <br /> NAILING INSML=IONSt FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. . <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> 870CMWI CA 95202 <br /> TOTAL P. I1 <br /> --- -- --- - - <br />