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SAN JC�aiQLJIN LOC.AI� t-rF:Ar .TH DISTRICT <br /> L&.. . GROUND TANK DISPOSITION TRACK APRD00RD <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 /> ensuring t this <br /> , 1f <br /> orm is complpted and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: Zs3�1 �+ �k6ZL-00 9-0 TC—)N <br /> TANK ID 139- � <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 2i ��F T (�vNSi <br /> Address: 1�-3� �2�1�F vj1 \ y P 2 r l'�, Zip: q3 Z? <br /> Phone#: ? -i,eio- ZcP <br /> Telephone: ) �d?��j��O Date Tank Removed: g l� <br /> **!t***x***t*#xtt**#tx***x**t#*#***#******x***#*x*t*****##******** *x* x*##****#***xx*xx**x <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: i_F1tj 6S <br /> Address: Q . I l� l SDN �..cl 533- Z1D: <br /> Phone#: 8 <br /> Authorimed 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 /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility <br /> �accepting tank. <br /> i Facility Name W ec �KJu AN r ' <br /> Address: 2j SS 2D. 2� MAd�P.I� C+� Zip: 673(f3 -7 <br /> Phone 1:7Q9-(o?3 - 2-2Zo <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> xx*txtztxt:*tt*tttxxttz*tx*x****#tztxxtzxt*tttt*xtt****t*xxxx***#*#xxzx*xxx****txzxxx*#*x*# <br /> BII 23 019 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. ARFIX PROPER POSTAGE. <br /> OWT Z 7��Q U SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> `�/Yv ATTN: UNDERGROUND TANK PROGRAM <br /> kt5 P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />