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i SAN JOAQbMN LOCMI, H AT.TH �ISTI2ICT UNDERGROUND TAW'DISPOSITION TRACKING RECORD **x***r,-�••+****k****k***k***k*****x**xx*x*xxxx**1t*xitA*xxx*itiFlr*ihltiexxxit*f!ltxit*itit**ihit*******x* SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to San Joaquin Local Health District within 30 days of acceptance of the tank by disposal or recycling facility. The holder Qf the permit with nuWmr noted below is reamnsible for ensuring that this form s completed and returned. FACILITY NAME:±k'a.ci FACILITY ADDRESS: _ G TANK ID 039- /D No�-- *xxxx*x**x*x***x****xk**x****x***xxx*xxxxkAxxk*xxx****x*xx*xx**xx*x**x*xxkx***********k** SECTION - 2 - To be filled out by tank removal contractor: Tank Removal Contractor Wit« ✓-v -c--sy 1cf Address:f�(C,�\ S r -- Zip: yfacS i n Phone#: Telephone: ('k i Date Tank Removed: xxxxx*x*******x*x**xxx****x**********xx*xxxx*R*xxxxxxxx*xxx*x***x***x***x**xx*x****kx*x**** 8"ION 3 -To be filled out by contractor "decontaminating tank": Tank Decontamination" Contractor:1c o �n Address: Zi Authorized representative of contractor certifies by signing below that the tank has been decontaminated in an approved manner as may be regulated by Department of health Services. SIGNATURE AND TITLE SECTION 4 - To he filled out and signed by an authorized represnetative of the treatment, storage, or disposal facility accepting tank. Facility Address: Date Tank Received: p. AUTHORIZED SIGNATURE AND TITLE *x***x***********x*****k*******x*x*x****xxx*xxxxxk**x****x*****x**xx*k**xx**k*x************ Elf 23 049 12/88 MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. SAN JOAQUIN LOCAL HEALTH DISTRICT ATM: UNDERGROUND TANK PROGRAM P. 0. BOX 2009 STOMT1M, CA 95202