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�� JOAlVIN LOCAi:, �rA.L.TH DISTE2IC',C <br /> UNDBR*JND TANK DISPOSITION TRACKING <br /> SECTION 1 - The San Joaquin 'Local Health District's Tracking Sheet will accompany each tank <br /> affixed with its site identification number, <br /> Joaquin Local Health District within 30 days of acceptance <br /> ceptance Sheet Sa to be returned to San <br /> recycling facility. 1Tte hold K o Hermit Ptance of the tank by disposal or <br /> Pns �rinW hat this •fo m is r ° r not'• brt <br /> t * i <br /> FACILITY NAME: I �LEk '9 SS OA S <br /> FACILITY ADDRESS: -t rn A 1 f� g?, P i,* <br /> TANK ID 039-;�5R7-p <br /> *R*ttR*t*!*t*!*!*t!t*ttw*twttlwt!lttw!*!ww!!wt!!twlwlttttRlRtt!!ttlRttttt"twltlwtlwttwltRlt <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal contractor: s <br /> Address: y31 W, i{T� WD 1+�� _6TO �'r4 <br /> Zip: ys3sl <br /> Phone#: <br /> Telephone: Date Tank Removed:- -� <br /> !*****!***t*t*!*ttRltlttwwttlwtRlRt!!ltttwwltltwtwlwltwlww!!!::lRtttwttwwwlw"ttwlwlswwtwtwR <br /> SECTION 3 -To be filled out by contractor "decontaminating tank"; <br /> Tank Decontamination" Contractor: M. A <br /> Address: tial W NTS %b zip: <br /> PhonaN:.�st�`3 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decon ted in an appy manner may be reguL3 <br /> by Department of Health Services. <br /> x�tAl�t!*!�*!!x�*t!*!*!**t*!t*w*!R*!*!t!!w!*!!***t!* <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank, <br /> Facility Name S EIvy—o <br /> Address: 41� W,i;'TA fb /h J1Ks1O ,� <br /> Zip: <br /> hone 2o9s�2 y � <br /> Date Ta Received: - <br /> AaA <br /> t**!**!!!R!!t!*!!w!t*ttwlw*lwwtwA lUTHORwtZEDtwtxNAtTwUREtx!lANDRlwlTsMxltlwwtwwwwltwltlttltlwwttwttw:w <br /> EH 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> AT K: UNDERGROUND TANK PROGRAM <br /> P, 0. BOX 2009 <br /> STDCKTON, CA 95202 <br />