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SAN JC JIN r Oo(=AL 111x.J��, DI StT`RI Gam' <br />UNDO"" -ND TANK DISPOSITION TRACKING RECORD <br />ttf ttftRtlltltttllttlftttRlt!!R!tlRtRRR;tR;RRRRtRlfRtRR;;tRlt;tf tlRttRlRRltt Rffftf if ltRlt;! <br />SECTION 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 <br />recycling facility. The hold * of reit vl h by disposal or <br />enaurina that this fora i. let--��-�-°— r rnt-" bel^ c ioi <br />FACILITY NAME: Color Snnt <br />FACILITY ADDRESS: 5400 E <br />TANK ID 139- <br />ft!ltttltllfRlRRtt RRlRRltltlttltC)�t;Rl1tR RlRRRRRflRRRRRRtff RRRRRf tf ttRlRRRRtf RltRRRtRtfft <br />Sl1CTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: JIM THl)aDG nT1 ,R, <br />Address: 351 <br />r. U. box s/, Lodi, CA 95241-0357 ZIP: _95240 <br />Phone#: __!209) 462-45x1 <br />Telephone:( I Date Tank Removed: <br />Rf tflttR lRRtftltRRftRltRltlttlRRYltRfRRtRtl;tRlRRRRt!•Rl1RtRR!lttRttf ltt;;;tltf lR!lttttt;R;;; <br />SWTION 3 -To be filled out by contractor -decontaminating tank": <br />fank Decontamination" dontractor: 0j0 <br />Eel. <br />Wdress : i Fn <br />Ip: <br />rnone#: <br />luthorized representative of contractor certifies by signing below that the tank <br />has been <br />+contanin ted in an approved manner as may be regulated by Department of Health Services. <br />.R tf tl lRttRlR;t;ltltltRttltR!!tRlRRlttSIGNATURE <br />t;ATI <br />�RttlTf•Rtlll ttRl;ltRRlRltllYt;;t;!!!!t!!!!!! <br />Se # <br />orag <br />t - To be filled out and signed by an authorized represnetative of the treatment, <br />forage, or disposal facility accepting tank. <br />Iacility Name <br />kiress : <br />12 <br />its Tank Recel <br />RRRlRRlRttttttltttRYtttfR;RRtRtUI*ORltEfDtllRRONll RTURERRANDRf RRTfkRRRIRlRf RRRfffflRRttfR!!lltl tlR <br />13 049 11188 <br />ILINO INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER pO87WZ. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STDO(TW, CA 95202 <br />