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0 <br />gprl JOAQLJIN LOC-zL HF��TH DISTRICT <br />.�OC4D TANK DISPOSITION TRACKING RECORD <br />' Joaquin Local Health District's Tracking Sheet will accompany each tank <br />xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx <br />SECTION 1 - The San Joaq i5 The Tracking Sheet is to be returned to San <br />of acceptance of the tank by disposal or <br />affixed with its site identification number- <br />Joaquin Local Health District within 30 days <br />recycling Facility. T holde of the rmi wit number not d below is res nor <br />sible <br />c...-.., ; t rnmoleted and returned • <br />FACILITY NAME <br />FACILITY ADDRESS: <br />TANK ID #39- ` <br />xxxxxxxxxxxxxxxxxxx <br />SECTION - 2 - To be <br />xxxxxxxxxxxxxx��*removal contractor*xxxxxxxxx x*xxxxxx <br />filled out by <br />Tank Removal Contractor: S o,r, <br />Address: <br />�I rj, 3D (j pate Tank Removed: <br />Telephone: ( a <br />xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx <br />SECTION 3 -To be filled out by contractor '%decontaminating tank <br />Tank Decontamination" Contractor: <br />Address: <br />#: <br />R <br />_DDE <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 />d <br />****xxxxxxxxxx*****xxxxxxxxxxx*xxxxg*******an*authorizedxrepresnetative*of*the*treatment,xx <br />SECTION 9 - To be filled out and si netank. <br />storage, or disposal facility accepting <br />Facility <br />Address: <br />Name 11rr�, - �%JTo�Q <br />Zi <br />G Phone#:�`r <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx <br />EH 13 049 12188 <br />MAILING INSTRUCTIONS: FOLD IN��H OARANN S�LEIEAITH DISTRICT POSTAGE- <br />MAILING <br />ATTN: UNDERGROUND TANK PROGRAM <br />p, 0. BOX 2009 <br />STOCKTON, CA 95202 <br />