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SALE4 0071,QUII•S 1�OC.7L11. III3'Iti..:C'II DIS'EIRIC'r <br /> U11DF(7(22CUIID V??K DISPO1111"I TRACKING RECORD <br /> SECTION 1 - The San Joaquin Local Nealth District's 'hacking Sheet- will accominny each tank <br /> affixed with Its site Identiflcatlon nomber..'! ' The Tracking Sheet Is to be rel.urned to San <br /> Joarptin Local Ilealth DlsCrict t,LI:hLt 70 days of nccepl:ance of the tank by disposal or <br /> recycling faclllty. 1b_e o der or_ I lie .I-rr --with ntunber noted below Is responsible for <br /> ensuring that this form Is completed and returned. <br /> FACILITY NAMES C'ti�a• l� �r P l�C °b', J A)�r `ti .It , t 7 <br /> FACILITY ADDRESS.-_A <br /> _7 T <br /> TANK ID 139- <br /> 1,314 - 07- - I 7000 C. A1. <br /> *R**R***k*********hR*t+****kk#**±t +'.f.*k***R+k*!.•.�! •k**'i***1************k***k*k*RR*R**R***RR <br /> SECTION - 2 - To Cr. filled ant by Lank r oval +-r, )tracCor: <br /> Tank Removal Contractor:/' N C r <br /> Address: �� . C / �m a)I � Zip: <br /> �y PhoneN: <br /> Telephone: 6 G pate Tank Removed: 3 —lG �Q / <br /> **R****h*RR******R*R*************************R*R******************************h***R*RR*R*** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": ' <br /> Tank Decontamination" ntractor S I I_1�` C' i )C - <br /> yy <br /> Address: Vzip: l7 gd <br /> Phonel: 9/ Z357 1393 <br /> Authorized re tl contractor certifies by s ning below that the tank has been <br /> deconta n an p ov d manner may be reg u by Department of Health Services. <br /> � SI 'IUIIE ANb TITLE <br /> SECTION 9 - To be fille out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name rr EU I G �cr�lA �T���)c k /I'��11 q. <br /> Address: -25 -TyW.1` ��v7 1\iCI�VYl66) 14" Zlp:/ ;�O) <br /> PhoneN• 23 9 <br /> Date Tank Received: <br /> AUTIIORI . , SI(�IAT RIF. 1ID TI1 , <br /> Ell 23 049 12/88 <br /> [HAILING INSTRUCTIONS: FOLD N HALF ID 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 />