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N � 8 N , "Anon <br /> S31N JOAUI IV LOCAL "MAL+A DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> kk**w********wkwkwkw*k***x**w***********k***w*www***x*****x*xw**x*****xxx*ww*w**xx*w*xx*xxx <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 permit with number noted below is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: LLIe O <br /> FACILITY ADDRESS: / L. G' <br /> TANK ID M39- 12,& - O <br /> SECi'ION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: L)LIL '2 �� 2e,JD n . ,C/�f>L <br /> Address: Q�L1r=�)C. In- I�I ' A C�(_r� ,n n C�Y--I- q T] )3—Z i <br /> Phone#: �� <br /> Telephone: ( ac"'I Date Tank Removed: <br /> ***w*********w*********x*w*k***k*k*k*x*w**k*****w*********w*kkk***k*****w*********xxk*x**k* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: _11w P1_� 1) , m -�� l ii i u �� <br /> / <br /> Address: 1'r� o1nY� 5 I( w.n �T�` Zi <br /> hone i: < <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 /> w*xxwx***ww*w**kk**xw*xwkk*www**xwk*w*w**kkkk***k*w****x*kkx*kkkww*xwkk****kwwx**x**kxwwx*k <br /> SECTION 1 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. /� 1 <br /> Facility <br /> (�Name � CI <br /> Address:i 1) Ihx r^� �;,[.� ti�nr� �. Zir: <br /> Phoned: <br /> Date Tank Received: <br /> .�✓'��Y�� /, X96 ''�iu� <br /> AUT IZED GNATURE AND TITLE <br /> Elf 23 019 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER pOSTAG 4 j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT p� <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> JUN 1 9 <br /> P. o. BOX 2009 =NVIRONMENTAL HEALTH <br /> STOCKTON, CA 95202 PER MIT/SERVICES <br />