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SAN J C)A N r"C)C12M[-' HEAL`T'H <br /> I STF2I C'r <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany <br /> affixed with Its site identification number. each tank <br /> Joaquin Local Ilealth District within 30 days of acceptance 9ofhthe tank eet Is obydisposa l to San <br /> recycling facility. > Y disposal or <br /> °omp ember not d j is testiao u hiA f.,' <br /> ensuring t 4-1,%- form i om late a <br /> FACI L I TX W1 : � C�1�� � CJ 1�'/ Uk✓�' Ty�/� <br /> FACILITY ADDRMS: �71 <br /> TANK ID p39- el <br /> ******atss*irs*�*atitsititarit****sat**situs*atsarsak ssssirssssararssarss*****arirssatsarss*sitssss*itsitsititsssatirs <br /> SDCI'ION - 2 -- To be filled out by tank removal contractor: <br /> Tank Removal contractor: <br /> Addrress- <br /> Zip: <br /> Telephone: ( } <br /> Dairs*�r*te Ta� Removed: <br /> Phone:*ssrtsarstar*situ*s*satsss*at at**sitssssirs <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: <br /> Zip: <br /> Phonel: <br /> Authorized representative of contrZactor 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 /> ***at at it at at*atssat,tirit***it*atsatitsat atsit*sitar,rsiratSIGNATURE <br /> itAND <br /> ssitTITLE <br /> �rir*itaratsar**at*ar*arsitatar it*ar*it it*ss*rrir <br /> SECTION 4 -- To be filled out and signed by an authorized represnetative of the treatment, <br /> **sits <br /> storage, or disposal facility accepting tank. tment, <br /> Facility Name <br /> Address: <br /> Zip: <br /> Date Tank Received: Phone: <br /> ****at at itatsssssatakatsssssitssssitsit�AUT110RIZED **UIs* *AND <br /> s*ITLP,- ssrt*sss* <br /> Ell 23 049 32/88 s*xar>tar*pit**writ***atsifar <br /> MAILING INSTRUCTIONS; FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL 11EALTI1 DISMrCT <br /> ATTN: UNDERGROUND TANK PROM M <br /> P- 0. DOX 2009 <br /> r <br /> Sx'OCKT N, Ch 95202 <br />