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or ­ <br />UNDERGROUND <br />TAM{ DISPOSITION TRACKING RECORD <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 rmit with number noted below is responsible for <br />ensuring that this form is completed and returned, <br />FACILITY NAME: S j2a S <br />FACILITY ADDRESS: J ,-�,�RQf� <br />TANK ID 139 /a4 91" - <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor:— Zfc <br />Address: C. C-4 Zip: <br />Phone#:�o� a <br />Telephone: ( a9 j .p0 Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decpntamination" Contractor: /U & pie/ &r - <br />Address: Sa y 10 96 Zip:3 a / <br />Sf r Phone# • 2noyj <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approsved manner as may be regulated by Department of Health Services. <br />SIGNATU1F± 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 <br />Address: <br />zip: <br />Phone # ..—"- <br />Date Tank Received: <br />AUT06RI'2 SI ATURE AND TITLE <br />E!! 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />