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ATTACHMENT 2 SAN JOAQUIN LOCAL HEALTH DISTRICT UNDERGROUND TANK DISPOSITION TRACKING RECORD x x x x x x x x x x z x x x z z x z z x z z x x x x z z x x x z x x x SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to San Joaquin Local Health District within 30 days of acceptance of the tank by disposal or recycling facility. The holder of the permit with number noted above is responsible for ensuring that this form is completed and returned. FACILITY NAME: (1� LP—i . _of TeiaL.S .I nn FACILITY ADDRESS: ' Z4ISS C,0er�RL I�o�WvJ �ID #39- -_ SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor:�Y1 C,� Address: �4ATrH Phone # Q09 - 5d' -9053 Ong.3 `TD (1A _ zip 95ssi Date Tank Removed_ I L 1 q x x x x x x x x x x x z z z z x x z x x x z x x x x x x x x x x x x x SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Ui "Decontamination" � Contractor n EC/oM C Address 4S,N w. H/3 Toi-1 g Phone# Q00-i- Sdq-Q 653 a O Q -%- O N Zip CI Z, 3S l Authorized representative of` contractor certifies by signing below that the tank has been decontaminated in an approved manner as may be re ul ted y Dep4rtment of Health Services. SIGNATURE AND TITLE * z z x x * * x z x x z x z x z z x z x z z x x z z x x x x x x z z x SECTION 9 - To be filled out and signed by an authorized representative of the treatment, storage, or disposal facility accepting tank. Facility Name CSC� Address (-ATL` H 4 . Phone# 2 O a - `-a y-cl�'S3 IYlO ��sTv C'A • zip 01SSS1 Date7)Tarxk Received ( . k A -,1, — � � . AUTHORIZED SIGNATURE AND TITLE * * * z * * * z x x x z z x x x x x x x x x z z z x x z z z z z z x x MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. SAN JOAQUIN LOCAL HEALTH DISTRICT ATTN: UNDERGROUND TANK PROGRAM P.O. BOX 2009