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Sat1L�7 aOA4JIN LOC"-.16L FIF.2'LT DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RF.70oRD <br /> t#*#t#Xt#**tXX*t#*#***YY**tY***Y******Y****#*##***!**YY*Y*Y****Y**Y**t***Y***YY***tYYY*tY <br /> \."TION 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 by disposal or <br /> recycling facility. The holder of the permit with number noted below is responsible�off_ <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: 15Kn15 SEVEI.CTt-t GTQEET � L�NC�S[t7ly W1AeKETI <br /> FACILITY ADDRESS: 1S61S^ SE1drn1TH SC'P_r_LTr LATKQDP . Ca a1S7530 <br /> TANK ID 139- 1-- <br /> ' <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Rex?val Contractor: :SE tw Cc*0 -�,_ <br /> Address: A-31 W. Hh-VCt1 QQ Zi c153S1 <br /> MODEzTo yCP% Phone#: 9 Saq_CUj51_: <br /> Telephone: Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: SE MCA <br /> Address: 431 W. i- mir_►4 RO Zip: 65351 <br /> Phone#: ( ) Sa`t_ej(o5 z <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> XXfitfiXlrtfitfififififi#fi#fifiY*#**fi*#Y#*t*#**#**X*Y*YYY*#*#*Y##***fifififififi******fiX*fi*kX****YR*X*t#fi tfiX <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Nuns_ LEVI j,4 Mme+ <br /> Address: L Zip: <br /> Phone#: 1 <br /> Date Tank Received: <br /> /A 'HORIZ IGNATURE AND TITLE <br /> Ell 23 019 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDIMGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />