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INDMRGROUND TANK DISPOSITION TRACKING p9aW <br /> #fttttt#ttltttR#t!!!t!t!!t!l�. .�##lttRtttRfltltlttttR!!!Rt!!tlfitltRttttltltRRlRlftlY!!RY!!! <br /> SEC!'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 wit►+ ❑�►o. no �+ low is zesa05a f.,r <br /> ensurim that this//form Is-c!omnle+ed <br /> FACILITY NAM <br /> FACILITY ADDRESS: � (3� <br /> TANK ID #39- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: l(�L_b <br /> Address: '13_l W . ��0.�C�n ) Zi <br /> K- 7� ( i r +4 <br /> Phone; -5 3 <br /> Telephone: CaO9 67-zI-9653 Date Tank Removed: <br /> ttttttttttttttttttttttilttltltltlt!ltttt!!!t!t#1ttt!!Y!!!!!!:!##!!tYlfttltf!!R!ltYRttltlR!! <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: zip; 953Sf <br /> �1ti�cLe��� , r A Phone/: �zU- (mss <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 /> #########tt*t#tt##t#tlYt!ltttRYYRttltttttlRlY!!!!!!!!t!!!t!Y!"1t"Rl1R!!!f#RRYYRlRRttlYt!!t!t <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, o��r��disposal facility accepting tank. <br /> Facility Name_'SQ-'c(NCKD -rl �/��'✓/ h{ �� �i L <br /> Address: /! A Zi <br /> 1: � U ( <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ######!#t#ttltt!!!!tt#tt!!tlRYt!lttY!!R!RlttltRRlttlt!!!R!t!t!!tRlYlt#Rt!lttRltRRtttttRlt!! <br /> EH 23 049 12/88 <br /> HAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATI N: LtMMGROI.tm TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTGN, CA 95202 <br />