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APR 27 190 14:24 R.H.I. SACRAMENTO 9166464679 P.3/3 <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />SECTION 1 - The San Joaquin Local Health District's Tracking She�iALH���i <br />will accompany each tank affixed with its site identificationy- <br />The Tracking Sheet is to be returned to San Joaquin Local Heath' <br />District within 30 days of acceptance of the tank by disposal or <br />recycling facility. The holder of the permit with number noted above <br />is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME:.......'� i t Y_ ' P fl i W <br />Aarr <br />FACILITY ADDRESS: Sia.`i(lk..y__TANK ID #39-- t-- <br />SECTION 2 - To be tilled out by tank removal contractor: <br />Tank Removal Contractor:„ <br />Address: S,c� T►i ( l� phone # t 22 �(`$.,` <br />Date Tank Removed -c� o ----- <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank "Decontamination" Contractor <br />Address w.phone# <br />9 <br />Zip . <br />Authorized representative of contractor certifies -by signing <br />below that the tank has been decontaminated in an approved m§neer <br />as may be regulated by Department of Health Services. <br />SIGNIATURE AND TITLE <br />SECTION 4 - To be filled out and signed 'by an authorized <br />representative of the treatment, storage, or disposal, facility <br />accenting tank. <br />Facility Name k ln� s d� <br />Address_.' Phone# 15. G '• 1'�J <br />Date Tank Received <br />AUTHORIZED SICdATL1i2E AND TITLE <br />MAILING INSTRUCTIONS: Fold in half and :Maple. Affix proper postage. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN : UNDERGROUND TANK PROMM <br />P.O. BOX 2009 1 5TOeKTONJ / CA g92V <br />