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Sp,N JOAC1•iJIN LOci&l+ H0Za,-rk*DIS'I'E2Ij1 13 1991 �4 <br /> UNDERGROUND TANK DISPOSITION TRACKING RDOORD ENVIRONMENTAL HEALTH <br /> PERMIT/S <br /> Sheet will accompany eaRch tank <br /> r**********zx*************L*moi*Health*District*s*Tracking <br /> *********************� *�'��'�*�* <br /> dCTION 1 - The San Joaquin The Tracking Sheet is to be returned to San <br /> affixed with its site identification numbers of acceptance of the tank by disposal or <br /> Joaquin Local Health District <br /> within <br /> t30 day, c ml,er noted below it resoonsib or <br /> recycling facility. <br /> a imss, t t•hiS form is COm L � / ��\ <br /> `� <br /> �/��.�� 1 T ( LR1 A L <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANK ID #39- 5�-- ---'- <br /> *****z*z*******z**z******z***z**zz**z********z**x****zz**********z**z**z*zz*z**z*z******** <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> 0 <br /> Tank Removal Contractor: Zi q $3 Si <br /> l ItTC Phone#: 4 S` <br /> Address: 100, A <br /> cL n . O,_S� Date Tank Removed: <br /> Telephone: ( _1 <br /> *****z*********z*****************zz*****z*************z********z****z**z**z**z***z****z*** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank <br /> St`.M <br /> Tank Decontamination" Contractor: q S�Sl <br /> 4 i FYRVC�-k RO Zip <br /> Address: sig � -- <br /> e tank <br /> en <br /> Authorized representative of contractor certifies by ; dnby Departmeing below nttofhHealth Services. <br /> decontaminated in an approved manner as may be reg y <br /> 31GNA'iVRE AND TITLE <br /> zzz*z****zz***********z****zz**************a**authorized*represnetative*of*the*treatment,*z <br /> SECTION 9 - To be filled out and signed by n <br /> al facility acceptino, tank. <br /> storage, or dispo <br /> Facility Name <br /> LES 4 al <br /> _ ZIP <br /> Address: LOn 4 ^ #: 4151 <br /> Date Tank Received:- <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Ell 23 049 12188 <br /> ` MAILING INSTRUCTION::.: SAN <br /> IN HALF AND STAPLE- AL•FIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. WXX2009 <br /> STOCKTON, CA 95202 <br />