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UMMOUND TANK DISPOSITION TRALXING RAOORD <br /> *R*;ARl�;�!„!!!kA*!�!ltttlttltttttlttttttttt#*Rt##RRRRAAAAAAAAAAAAAAAAAAAAAAAAAAA###***YR*'* <br /> SWrION 1 - The San Joaquin Loral 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. <br /> ensuring hat this form ia� rlete' any; xgturned• <br /> FACILITY NIT: c: <br /> FACILITY ADDRESS: <br /> TANK ID <br /> ##Y#*#**R*R#RY#*#**R###RtY xR xR*k***t***R#RR*****#*#**R*R###RR*##YYY#**R***#Y#*##**RR*R###R <br /> SECrICN - 2 - To be' filled out by tank removal contractor: <br /> Tank Remova--yyl ,,C,,o��ntractor:_ )��/� �vAl �/1 /t c �k� 1 r� <br /> Address: 12 L1Q (� 1 E�� , �� f 'A C1,S7i zip <br /> —T Phone# S,35- <br /> Telephone: ( ) !kite Tank Removed: y <br /> ##RR##tRR**RRR****RYRR#RR*R*RR*RRYRRR#*RR*#R*YY!**Y*R**#R1tY#YYYR���rI1111A�((((II�ISRIS�fiAl:ttttTt�t <br /> ^'��"•• •' .1 ra�aw ✓ur ✓y VVa KaeV l✓.. 'Lgl.Vlll.diYlfa L;Og 1;An1(•'./ <br /> Tank Decontamination" Contractor: I� {/�j r n . [)/L.Q j <br /> /pn � !-r. ' l.^d—y�fs7Zl Zip: <br /> Phone#: Js— <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> docontaminated in an approved mariner as may be regulated by Department of Health Services'. <br /> SIGNATURE AND TITLE <br /> #RR*kRt*RR*##R*RBBB#*R#R*Y*t*RR*****R##*RRR*#R*RRk#RR##*##RRR###*#*#*****RR*##*t#YRR**#R*## <br /> 'k 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 <br /> Address: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AVL1iURIZtV SIGiAUFZ AND TITLE <br /> Y#*#**R*#R*#R#YR###RRR*R**R***YYY#YR**R*R*RRR*Y#YYR**#*RR#*YYR*#YR##RRR#RR*#tYttRY##R#*R### <br /> EH 23 019 12188 <br /> MAILING IHSTRUOTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAG'6. <br /> sAN JOAGUIN LOCAs HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCMWe CA 95202 <br /> ,3 <br />