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SAN .�C�AQIJ2N LOCAL HF_,.�,I.,TH D2STRICT <br />UNDERGROUND TANK 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 ,permit with number noted Mow is responsible for <br />el2suring that this •form is completed and returned. <br />FACILITY NAME:-- I�AVICS S �'�� l RO4220-S <br />FACILITY ADDRESS: ,� <br />TANK ID 139- U4 <br />SECTION -- 2 -- To be filled out by tank removal contractor: <br />Tank Removal Contractor: `� c <br />Address: c. /�G x _ n 9 F 7- C ZLLE nr C' <br />.. -_Zip: <br />Phone# : <br />Telephone: (Jo2) OQ(3. Date Tank Removed: <br />SECTION 3 --To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: cf Zip: <br />ern. 7-r- ..r3C�ff �__ • - -- Phone# : 4/4.-r Q— <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 />SIGMA AND TITLE <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 <br />Address: <br />s Zip: _�' 2 <br />Phone # : G s 9 a <br />Date Tank Received: <br />ALfEPWI'ZED SIGNATURE AND TITLE <br />Elf 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 />