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17� A-Ol .5'1't•C11..:'1' <br /> UNDERGROUND TAMC DISPOSITION TRACKING REXRD <br /> *t*##iti1�IRRiRRii:liiiitfftlfttfftttttttttttt#***#**RRRRRAAAAAAAAAAAiiiAAAAiAAiiiiAA**i*Rk#*'fi <br /> SECTION 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. <br /> ensurino ha�thlg fnrm is O *�1 C��r'�r�turnea• I� --••� �a �, <br /> 6ACILITY NAM ;0^ <br /> FACILITY ADDRESS: 2rl tjq In, <br /> TANK ID 939- - <br /> 4tt*#R****#**#R*******tR*#** <br /> SXTION - 2 - To be- filled out by tank removal contractor; <br /> Tank Removal Contractor:�0PA r 4 A <br /> Address; <br /> �.. zip. <br /> E! PhoneY: <br /> Telephone: ( ) Date Tank Removed: <br /> RRkk4k!*#t*RR****t*!tk#*RR**RR***ttR#R*RRRRRkt44t4t**RRRRRRRkR4kII�������x��fi�I�1'(YR�I�tiitti�i <br /> -+ v.. r .r .,.r maw .,u.. V1 ..V.IWeItV.. "4GLV11WIY1lidljng uanK-. <br /> Tank Decontamination" Contractor: 14Z — <br /> Address,: 'Zo O� /.(��10„ �zi• � �zL� s3 zi �J <br /> PhoneY: <br /> Authorized representative of contractor certifies by signing belov that the tank has been <br /> decontaminated in an approved manner be way be regulated by Department of Health Services'. <br /> 1 <br /> SIGNATURE AND TITLE <br /> *k*i**#*iR*R4R*RR*##*R*t*k*4*fiRt*#*#R*tRRRR*RR*RR*k*ttkttt*tR*kttti4ttk*RR*****tfi4tRR*t**ii <br /> ' SECPICN 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or dispoeal facility accepting tank. <br /> Facility Name <br /> Address: <br /> 21p: <br /> PhoneY: <br /> Dote Tank Received; <br /> MJ111UK1ZW SIGNATURE AND TITLE <br /> #R*#i*R#i*tikk4**AkRt*Ri*R**#t4ti4Rk4*ttRRRttRi4t44t**RRR***R*RRt#R##**#RkttftR4ik#iR*RR*ii <br /> EH 23 019 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER pOSTAGB. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> AM: UMERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> B70CKTONF CA 95202 <br />