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SALN J OAQUI H r_.C>c Ax , H UU,TH I S TR Y CT iJN MM& TANK DISPOSITICN TRACK YNG xxx*xxxxx**xrr*x****xxx*x*****�rxxxtx*xxxxxxx,rs*xx�txx*xxxxx�txsx:x*xxxxxxx**x#�rx*�tx*x*x*xxs�e�rx SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to San Joaquin Local Health District within 30 daya of acceptance of the tank by disposal or recycling facility. The holder, f Un q that t s form is comx)let = a. , helot b for ile FACY LI TY NAM: ' Ui11 T ( A/ I SJ,4 FACILITY ADDRESS: TANK ID #39- xxx*xxxxx**xx***sxxx�x�*x�*xxx**x*xxs�txi�**x�rx�txxxx***xx*sit*�tx*xxxx*t*x*x�tx*x�rx*x*x*xx*xxxxx SECTION - 2 - To be filled out by tank removal contractor: Tank Renvval Contractor: Address: Phone#: Telephone: (`169 -Q Date Tank Removed: ***X'*"k7t*****x*x**'*x****xx'A'**xx'�`x*'**'********�'�•x**x*�'***�'*�'�'**�•�"*x*x***'�'x x��'***�'**xx *"*x*�'xx*� SECTION 3 -To be filled out by contractor "decontaminating tank": Tank Decontamination" Contractor: p Address: y,1 `CA Zip: .. Phone# : in�2_9L2 Authorized representative of contractor certifies by signingbelow that the tank has been decontaminated in an approved mariner as may be regulated by be of Health services. SIGNATURE AND TITLE SECTION 4 -- To be filled out and signed by an authorized represnetative of the treatment, storage, or disposal facility accepting tank. / Facility Name �•� - 6C�a `tea • )- ff - Address: zip: 2t,� Phone # : Date Tank Received: AUl'iiCRi ZED SIGNATURE AND TITLE xxxxxxxx*xxxxxx*xxxx*xxxxxxx*xxx**xxxxx�*x*x*�rxxxxxx*x*xx*�txx*xxxxxx****xx*x*xx*xxxsxxxxxxx EN 23 049 12/88 MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. SAN JO QUIN LOCAL HEALTH DISTRICT AT TN : UNDERGROUND TANK PROM M P. O. BOX 2009 STCOKTON, CA 95202