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SAN JOIN LOC-Ar IIEz'r•' DISTRICT <br /> UNDERGROUND 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 /> 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 for <br /> that this form is completed and returned <br /> FACILITY NAME: 15G AG7 SEX/F_ .,a -1 5�2EET--� 1-�N FluMPjQK�TI <br /> FACILITY ADDRESS: 1_C�05 15197VENITN SiP-r-En- <br /> TANK ID #39- / SO - 071 <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SE MCO <br /> Address: A--31 [A) NPcTC° R4 Zi 53Sl <br /> MODEZ37TO �S Phone <br /> Telephone: ( :00( Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: �I`"cA._) <br /> Address: 431 W. i-1hIlCk RD Zip: - 3S1 <br /> Phone#: QE) Sat—` 65_� <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 /> Pit MM- <br /> Q-SIGNATURE AND TITLE <br /> ******xx*x****x**x**x*xx*******x**x**xx*xxx*********xx*xxxxx**x**x*x***x**x***xxx**x*x**x*x <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 Name LEVIKA METAI-5 C.C� Q <br /> Address: (noa 4L =Qr. T puck4y_/M rs .CA Zip: � <br /> Phone#: 611S 236- 060 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *Y***x*X*xx**X***xxxX**x***Y***Y****Y****x*xxwx****Y*x***************xx*Y***x*** ****xx*** <br /> Elf 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATM: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />