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• • <br /> SAN .j0AQUIN LC(=Aj,, HEALTH DI STRICT' <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ct' <br /> sTracking Sheet <br /> c�CTION 1 - The San Joaquin LocalHe lth DistriThe TrackingSheetislto bereturnedach k <br /> rnedto San <br /> affixed with its site identification <br /> r. <br /> Joaquin Local Health District within 30 days of acceptance of the tank by disposalborr le for <br /> recycling facility. T' older of the aermit with numbs n e �p <br /> ensur'na hat this form is com _eted and_returned, <br /> FACILITY NAME. V5 t S_ E�/ e.Ci'a`-1 i2 E"� L1 N(-� tu u•r� a�P tiC `� <br /> FACILITY ADDRESS: 1 �.t`LT Z,_,gT�-i,�P <br /> TANK ID #39- - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SEtn <br /> s - l t�F PITC Z Uf <br /> r �Address: % Thane#: <br /> Telephone: (.a021 -) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: �''t <br /> Address: <br /> +31 Rk�� RID Zip: <br /> G <br /> Phone#: 4"' k <br /> Authorized representative of contractor certifies by signing below tMt the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE,AND TITLE <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. . <br /> Facility Name LEVI P'a #AU- <br /> Address: L Zip. — <br /> Phone#: 4r5 C <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> S!r 23 094 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. Ar-FIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDMGROUND TANK PROGRAM <br /> p, o. BOX 2009 <br /> STOCKTON, CA 95202 <br />