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6 <br />Aja * 6 <br />SAN 17C>2110 JI N L,0C_AL HMAI •TH I7I STF2I CT , <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />ION 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: �'� e!!! <br />FACILITY ADDRESS: <br />TANK ID #39- <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal <br />.4.,-1;�, � , <br />Address: <br />Contractor • _azo`'" <br />Q. WWI <br />Telephone: ��)j�Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: <br />n <br />% V <br />ff�y <br />zip: , <br />Authorized representative of contractor certifies b signing below that the tank has been <br />decontaminated in an approved manner as may glated by Department of Health Services. <br />�� CNAZ AND TITLE <br />SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Name <br />Address,�d�3�i/Yj[i �vLc Zig;o <br />Phone # : <br />Date Tank Received: <br />?WAQWM SIMATURE AND TITLE <br />Ell 23 049 12/88 7-991 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSrN% <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON. CA 95202 <br />