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SAiVi .7OAQU=N LOC''_AT . HEALTH D= STRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *k�kkkkick*�kYtkkk*kickk*kkk��****kkk�kk*kit3rk*kkkk*k*k*k*�******k�k�kk*ick*kik***��irk*�**�*�**k�C�C9c** <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 below is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: 514cw �i✓�-�/IL �7�T1C:� <br /> FACILITY ADDRESS: g3iS A F_:-124_Cx> !S��I✓ S CV— c> <br /> TANK ID :#39- - <br /> SECTION - 2 - To be filled out :by tank removal contractor: <br /> I <br /> Tank Removal Contractor: <br /> Address: Z /� /�. \/, zip: 94545 <br /> A. Phone#: Z4is)763- -IS00 <br /> Telephone ( IS' ) E33-7 SU U Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination". Contractor: —�L:TTI IZ- &4L-\1 <br /> Address: zip: 94545 <br /> p• n. A Phone#: �qIS� l�3-?SCO <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 /> *kkk*ick*ickkickkkkk.kkkickick*kkkkYck*kkkkic**kkk*k�Ckkickkk�kkkkkk*ickickic�F*:******kk9c�ckicicickicickkk**�k*kk <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 24 <br /> Address: ` Zip: 91agi <br /> f44C_4AW,4-jb /s. Phone# <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> E1! 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 />