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SZ�N JOIN LCm=AL HMAXL.T4j0I8-M1CT <br />UNDE nMWD TANK DISPOSITION TRACKING R•EcoRD <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 pealt with n LMr now btlow In res2gpsl�le for <br />FACILITY NAME: ��L)1V TWM Sr 14 hf - <br />FACILITY ADDRESS:_._ /�/ /VO2'Tf-� /�1 _TYr� 19 , 04. /63-36 <br />TANK ID 839- / <br />SECTION - 2 - To be killed out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: <br />Telephone: '1Eo9zz.a "� �� 3 Date Tank Removed <br />SECTION 3 -To be filled out by contractor "decontaminating tanks: <br />Tank Decontamination" Contractor: (,_ <br />Address: --4?�i <br />Zi <br />is�Z_ <br />3 <br />p• 9s.3sr <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 />SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Name `4`C�C� - Kl,. / e�r TAGS <br />Address: <br />Date Tank Received: <br />FOWNSM <br />ORM-IMM - 0 <br />ALMMI ZED SIGNATURE AND TITLE <br />EH 23 O49 .12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAOUIN LOCAL HEALTH DISTCRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOC KTON, CA 95202 <br />