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SAN J'QAAIN LC M=AN-- HEA1--TH1*ADI 3'rRI CT <br /> D TANK DISPOSITION TRACKING RECORD <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 /> Joegain Local Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. <br /> �� �-17�� �Dr`-$ ('fYilli"1�of'AI� �►v� rair r^i <br /> ` J <br /> FACILITY N�s �� ` • l <br /> FACILITY ADUMM -) In <br /> TAMC ID 139- <br /> sssrtssssssstsss�e�r�tss*sfss�ts:rs�rssss*s*s:�rss <br /> BRLTION - 2 - To be filled out by tank removal contractor: <br /> Tank Rowyal Contractor: Q C 1 t p <br /> Address: ti n�.4 _.fl cr� ,� ' T C_ � CY� zip: <br /> � I Phone#: <br /> Telephone: �� `7L,r - cl q I( [ate Tank Removed: <br /> ssssssssrrrr:rs�rsrts�tsssssis�tsrtss,�sssrrs*,t,r,r**s***;ass*ss#sssw�r,t#,rs�rs,rssssassss*s�rsssss�rssssss�tss <br /> 9i MOU 3 -To be filled out by contractor "decontaminating tank": <br /> Tank DOMteAlnetion" Contractor: <br /> Address: <br /> Zip: <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> deoan#aaa4tnated in an approved manner as may be regulated by Department of Health soxvic". <br /> SIGNATURE AND TITLE <br /> 5=10M 4 To by filled out and signed by an authorizes] reprssnetstive of the tre:atant, <br /> storage, or disposal facility accepting tank. <br /> Facility Nlaaae <br /> Address: <br /> Zip: <br /> hone#: <br /> Date 'tank Rep ivrd: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> sssstsssstssssssssssssssssss**sssss#s####�r##s#�***,�#�*,�****#**##*******####ssssssssssrr*sees <br /> 811 23 049 22/d1 <br /> MAILING INSZRUC TIONS s VIOLD IN HATS AND STAPLE. AFFIX PRopER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN., UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> 8TMKTO N, CA 95202 <br />