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- r1�^'"'.'�+J ".' - - '., - � r• ^ - t:-.'.�,� yv-Sia•'�-��."�:-?-_4-+„e "'."^Yi++„�}`.'y-��v"i: r <br /> ..*_. <br /> i <br /> S�iN JOAQUI N LOr^�br. HE1niL�TH DI STR=G"T <br /> ' UNDERCROLUD TAMC DISPOSITION TRAOCING REmRD <br /> ttttlit•!*tt!*tx�ltlt!!!t**!t!t****!***t!**#*�**sl**it ie!!4***t!!****!itlt!***!*!***!tt**!it**!!tt*� <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 ther with nUMI&r notlov is re522nsible &r <br /> eaguring that this form is completed and rej ned. <br /> 'FACILITY NAME: -/ <br /> FACILITY ADDRESS: r j <br /> TANK I D 139-_ <br /> ttttxt*ext*x•***!!* <br /> SECTION -- 2 - To be filled out by tank removal contractor: <br /> �J rr" <br /> ' Tank Removal Contractor: � <br /> �f Q '�+ evhL�t, rVi�CS_ <br /> Address: Al, /ff rr= Zip: "$3 <br /> Phone#:(fid)W-9/�19 <br /> Telephone: ( -) yZ6<' - (&/tet Date Tank Removed: <br /> 0 *****t*tx <br /> SECTION 3 '-To be filled out by contractor "decontaminating tank":. <br /> Tank Decontamination" Contractor: flatp✓+d -- <br /> Address: Zip. <br /> ' Phone#: <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 /> S I[MATURE AND TITLE <br /> x!s*atx**t*xx�r*���*xx**�lxx***xxx�**sxx*xxxtx**x*�t�a****x*xxxx!*ax*txt***,r*ttlx*!**tttt*t*! <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 /> J <br /> ,Address: Zip: - _ <br /> Phone—#: <br /> 'Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> V***x#�x*s*x=*tt**rr*,r**atlx*x**�:*****err*xx*x*t*xx*r�yrit**xxxwt:t*t�tx*t***tttt***lttt!llttt**t <br /> 1 13 049 12/88 <br /> MIJAILING INSTRUL"TIONS: COLD IN HALF AND STAPLC. AMIX PROBER POSTAGE. <br /> ' SF's JOAQUIN LOCAL H LTH DIS`iRICT <br /> ATTN.- L NDERGROUND TMIK PF(OGPAM <br /> P. o. BOX 2009 <br /> S TOTON, CA 95202 250 <br />