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• 0 / c,�prl JOAQZJIN LOCAr-• HE2''='TH DISTRICT U4DERGROUND TANK DISPOSITION TRACKING RECORD ct,Sheet will accompany each tank xxxxxxxxxxx*xxxxx***xxxxx*xxx*xxxxxx*xxxxxxxxxxx*xxx***xx***x*xxxx*xxxx*xx*x*xxxxxxxxxxxxx SECTION I - The San Joaquin Local Health Distr1ThesTrackTracking ingSheet is to be returned to San affixed with its site identification number• withinict 30 s onsible for serholderofthe darmiofwitr noted below is re acceptance of the tank by disposalor Joaquin Local Health D recycling facility. - T - _ mmnlated and returned• FACILITY NAME:___ d i 301 taaPde� sere G e- ed. /4C N FACILITY ADDRESS: -0 l 5 C) r e ur�J q� So %icy TANK ID #39- 17--=— xxxxxxxxxxx*xxxx*xxxxx*xxx*x*x x*xx* xxxx*xx* *x*xx*x * *x**xx**x**xxxx**x*x*xxxx* SECTION - 2 - To be filled out by tank removal contractor: Tank Removal Contractor: r Zip: Address: Phone#: Telephone: (,1.L1_)30Date Tank Removed: *xxx*x**xx*xx*xx**xxxxxx*xxx*x********xx*xxxxx****x*xxxx**x*x****x*xx*xxx*x*xx*x*xx*****x*x SECTION 3 -To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: !- I C �, ��2Ph Decontamination" n /7G(ST!YlJ Rd.$ JTZ �bA� _Zip: Address: %9rr L Phone#: Authorized representative of contractor certifies fiess bsigning Dbellow that tentof Health the tank Services. decontaminated in an approved manner as may regulated by SICitATURE AND TITLE xxx*xxx*x*xxxx*xx*x*xx*xx*x*x*x**x*x****x*xx*xxxx*xxxx*xxxxxx*xxx*xxxx*xx*xxxx**xx*xx*x*xxx SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, storage, or disposal facility accepting tank. Facility Name /,i„• //L 6 ` p a 7 / l ll%C��ul lJr, ; Y-oc:,� � Zip: / Jia 0 3 Address: Phone#: o Date Tank Received: AUTHORIZED SIGNATURE AND TITLE Eli 23 049 12/88 MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. SAN JOAQUIN LOCAL HEALTH DISTRICT ATTN: UNDERGROUND TANK PROGRAM p. 0. BOX 2009 STOCyTON, CA 95202