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'• `ter <br /> SAN 0O2)L0LTIN LOCAL, HFA.r.TH D2 S=1 CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ****7r***xxxx�xx7ktCyt7c]t�7k1t�*�*k*7t*******7r*'�**7�ticlCxxx7t1t7txxxxytRx7rx�ItYf)1r71rylt91tir71t 7k:1�'*7t*7t it 7t�t*�Y�*Ikx7tyr�k)Ir7t7rk <br /> SWrION l - 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 Qlder of the permit with ngMj&r noted below is re--ponsible for <br /> ensgring that this form is completed and returned <br /> FACILITY NAME: <br /> FACILITY ADDRESS <br /> TANK ID #39- <br /> �x�t**xx�xxxx�c�r�cc****xic#xxx*xxxx�c�:xxxx�r*:t*:t*t:x:t*x*x*x***xarxxxxxx�rxx*�r�t*****xx*icxxxxx�t�r**�c*,t,e <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: DECON Environmental Services, Inc. <br /> Address: 26102 Eden Landing Road, Suite 4, Hayward, CA Zip. 94545 <br /> Phone#: (415) 732-6444 <br /> Telephone: ( 415 ) 732-6444 Date Tank Removed: <br /> ***xx*xxxxx�rx***xxxxxxxxx:rxx*xxx*xrxxxx�t�c*x**xXxx:t�rxxxx**�t*****xr*x***xr**xxx** r*�rxxx*x***: <br /> SFS'"ICN 3 -To be filled out by contractor "decontaminating tank": <br /> .Yank Decontamination" Contactor: DECON Environmental Services, Inc. <br /> Addre=a: 26102 Eden Landing Road, Suite 4, Hayward, CA Zip: 94545 <br /> Phone#: (415) 732-6444 <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 /> SIGNATURE AND TITLE <br /> i1ru7Cit7Ciex*X�ex�e�e**'k�kx�exitirx*irltxxYtX*iexx*xxxyexx*iex3cxX:kkt:r�r:tic*:Riexxzxxx**ic*Xx�exx*ie*xie*xxxx****irxxX <br /> SECTION 4 - To be filled out and signed by an authorizL-1 represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: zip: <br /> Phone#: <br /> Date Tank Received: <br /> A11fHORIZED SIMATURE AND TITLE <br /> *x*xxx*x**xxx*x�r***xxxxx****xxx*******x*�c***xr*xzxxx*x*x*xx�tx***xxxxx*rr*x�r�rx**x**xx�r**xr*xx <br /> Ell 23 049 12188 <br /> \,-riAILING INSTRUCTIONS: TOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PRO(r%.M <br /> P. O. BOX 2009 <br /> STOCXTON, CA 95202 <br /> 9 ' d cS :60 68/01,180 _ -- WOdj <br />