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^nN JO,ZyQVIl�I LOCd\L I-I.GAL'I'I-i DI SSTE2IC'i' <br /> UNDERGROUND TANK DISPO^uITION TRAM UG REODRD <br /> *k********R**********k******************R****hkkk**k**khk**k*k****hhR*R**kkk***R**R*R*R**R* <br /> six.`rim 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> a[Eixed with its site Identification number.'; The Tracking Sheet is to be returned to San <br /> Joaquin Local 11palth District within 30 days of arceptance of the tank by disposal or <br /> recycling EacilKy. ' . T :eh�de�gs the_ix�rmlt. vllI nwnber noted below is resuonsible for <br /> ensuring that this form is completed and returned, <br /> FACILITY NAME:_ _ ��• l� r r Lt( !e. / 111�' <br /> FACILITY ADDRESS: 172' h.' , 1Cit hrAL 1- ALL., lir Tt'AG1/ <br /> TANK ID 139- 139G - t)3 <br /> *R*RR**k*h*k**Rh*h**kh*k*kk**k**hRhh***hk*RR***hk***k*�k******R**h*h*khk*kkRkRR*khk*hkhRhRh <br /> SEC[ION - 2 - To be filled out by tank removal contractor: i r ' <br /> Tank Removal Contractor: J44UN , <br /> Address: S N, P L T Zip: QS 37� <br /> Phonel: <br /> Telephone: (�Qq) 3S'�12Date Tank Removed: 3 —16;^ F q <br /> *Rkhkk*h*hit iYkAlt**khk*kkkkkk*k*R**k**kR***kk*hhRk**********k**kk***kkk*kkk*kkk*hlkkkkkRkk*hhk <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: ' l ( il"1`G�SDiV lIU/G� <br /> Address: <br /> tri T f�R ��y��I1'l�V1V► ln�j l� CV7 ' Zi <br /> Phonel: 5 9� <br /> Authorized represet ative of contractor certifies by signing below that the tank has been <br /> decontami d Ii an approved nner as regulated-by Department of Health Services. <br /> SIGIIATURE A D TITLE <br /> R**hkh*** kkR**** Rk*k*******k*R*k*****R*kk*** *kk*k**R***k*Rk*h**kk*kkR*h*RkR*hkhk*hR*R*R <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: OA Zip.@ <br /> I/ Phonel' ?3 <br /> Date Tank Received: (q r <br /> i V r•�.rl <br /> tA� O I ED SICTIA AND TITLE <br /> ***kk****k*hRk*R*R*h*******R********* k******* R*************k******** hkR**kh*RhkkR**kRk* <br /> Ell 23 019 11/88 <br /> HAILING INSTRUCTIONS: FOLD IN FIAIF AND 3TAP AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROMM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />