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r Y90 14:24 R . H . L . '�CRAMENTO 9166464679 <br />MAY 15 15000 <br />NVIRONMENTAL HEALTH <br />SAN JOAQUIN LOCAL HEALTH DISTRIcIPERMIT/SERVICES <br />UNDERGROUND WANK DISPOSITION `TRACKING RECORD )� , P) <br />Q11h <br />SECTION 1 - The San Joaquin Local Health District's Tracking Sheet <br />will accompany each tank affixed With its site identification pambe,.. <br />The Tracking Sheet is to be returned to San Joaquin Local Health { <br />District within 30 days of acceptance of the tank by dis opal or <br />recycling facility. The holder of the permit with number n 4 ALHEAUP <br />is responsible for ensuring that this form is completed and retur e�F�`��r�" <br />FACILITY NAME: n-�Y "_yQ.Q Hta f" <br />FACILITY ADDRESS:—_,��1. 1 tc'`�'(i�C TANK ID #39- ! '7 -_ <br />SECTION 2 - To be filled out by tank removal contractor,, <br />Tank Removal ContractMor : -Et <br />Address: t� � i`' '_ U � Phone <br />x i p !g„�-�Yo� <br />Date Tank Removed --�- C <br />SECTION 3 - To be filled out by contractor "decontaminating tank".. <br />Tank "Decontamination" Contractor <br />1+ddress� �4 S i- phone # S <br />Aut, zed representative of contractor certifies -by signing <br />be ow hat the tank s been decontaminated in an approved minner <br />a ma be regal Department of Health Services. <br />SICNA'IVRE AND TITLE <br />SECTION 4 - To be filled out and signed by an authorized <br />representative of the treatment, storage, or disposal facility <br />accepting tank. <br />Facility Name <br />Address, 955; Phone # �Al 15- 0 55• I SI ' <br />Date Tahk Wok i <br />AUTHORIZWSI� AND TITLE <br />MAILING INSTRUCTIONS,. Fold in half and :Maple. Affix proper postage. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P.O. BOX 20091 5TOC KTO tV I CA q snot <br />