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SAN .70AQUIN LOCAL HEALTH DIS*rRjCT <br /> UNDERGROUND TANK DISPOSITION TRACKING REOORD <br /> ■RR#RtR*RRtttRR*****#****tRRt*******fi******Rt*##*fi*fi***fi****##*R*R#R*#RR###*#**t#ttRtt*#*** <br /> SECTION 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 oermit with numbernoted below is responsible for <br /> ensuring that this form is cgn eted and rater eDyL <br /> FACILITY NAM: 5+C)LL+011 (� \ �I*,LLssiC_iel ,) q <br /> FACILITY ADDRESS: '1A1 GAAUS0A 071 dlbLK1m LLl ISC�O <br /> TANK ID 139- - <br /> RR##*t#R#tRR##ttR#**R*#*R###**tR**ttRR***RR*R*tRt#*t**RR**Rt*##*#*t**RR*t**Rt**4####tt#***# <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: hLc:(S1DYl f <br /> s vca AL <br /> Address: i041 :5 . � (-"k EM Q."e Zip: 9Sao(o <br /> � � Phoner: (:IN 6T 7771-1 <br /> Telephone: ( 1 Date Tank Removed; <br /> RRttt#R#Rt#t#tRR#tRt#RR##RRR#RR#RRRR*t***tR*R*tR*Rt**R#tR*RR*#R*R*RRR*RtR*#**#*##*##ttRRR*# <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: <br /> Zip: <br /> Phonel: <br /> Authorized representative of contractor certifie 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 /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name EC\LSotl JN�L. <br /> Address: a55 �& c 116C\ Zi g4®Ol <br /> �V wioh R Phoneli 14:51 335-1i3 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> 6N 23 019 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />