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,v z <br />SAN 70AQxJT N LOCAL HmAT •TH D2 STP Z CT - <br />UNDERGROUND TANK DISPOSITION TRACKING REcoRA <br />C***wwwwwwwwwwwwwwwwwwww*ww*wwwwwwwwwwwwww��**wwwwwww��*�**ww*****��**��ww*ww**�***wwwwww <br />CTION 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.i�, ho: der of tF►+ rmlt wlrh n�m►,Pr .,.,t w <br />-.C�-c urin--ted <br />Q_-ls resY)Ofl5ibt�� f� <br />- - 9�,�at t l;s f x►� is ro►nnl e �r�d r��t�trrlecl__ <br />FACILITY NAME: <br />FACILITY ADDRESS: e ��' •�r� /� • <br />TANK ID 139 -,moi _ U 2 <br />w*wsww*w�rwwwww*wwwwwwwwwwwwww*w*w**ww*****wwwwwwwwwww�*irw�*!r***fit*/*it�it*7k*Yt*1t**fit*it**itx****** <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: <br />:�.QzO Gip.-. <br />1p: 'rte/ <br />r <br />Telephone: ��) �-"� �l�d`—' Date Tank Removed: <br />w*wwwwwwwwwww,r*w**x�r*****w****rt�r**rt**w*rtrr*rrwrritw*ft*******w*w*w***x*rr***wwrr*rr*ww**w****ir�rwrtww <br />SWTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: C5��6E7Z elvoz�p_,_ <br />Address: <br />ip. � 1� <br />Authorized representative of contractor certifies by signing below t1><tt the tank has been <br />decontaminated In an approved manner as may ted b <br />y Department of Health Services. <br />,t31(T1A11J►tTs AND TITLE <br />wwww****wwwwwwwwww www **,�*x*,r***w*xx�t*w*�rw�rw****�****x******x►r�r*rt****x�*****,r**�*w <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 Nameyl��� <br />Address F' <br />T0eel-_Z62i 5' ell <br />Date Tank Received: <br />wwwwww*ww*www****wwww <br />Ell 23 049 12/88 <br />MAILING INSTRUCTIONS: <br />*wwwwww*w**irww <br />Zip;-,, .�o?l� J <br />#: - 5 <br />UILBATURE AND TITLE <br />ww**wwwsrwwwwwwwwww*******w*wwwwwwwwwwwww*www*wwwww <br />FOLD IN HALF AND STAPLE. r..IX PROPER POSTAGE:. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATM: UNDMGROUND TANK PROC R- M <br />P• 0. Dox 2009 <br />STOCKTON, CA 95202 <br />