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UNDERGW 'D TANK DISPOSITION TRACKING RE D <br /> lttL�!!!!!ltltt!!t!!;!t!t!l;t;R!!t!!!lRtt*t!!*lRtRtlRltttfttlttRttt!*RRtt!►Rt!!tltt!!f!!tt <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 h`10w is rPanQn4ih1e for <br /> returned <br /> FACILITY NAME: Idyl &I(CVN0L� <br /> FACILITY ADDRESS: �S� /N LJJ Ti?!A-,L" <br /> TANK ID 139- 115 <br /> IRtR!!R!lYRt!*tttt!!t!!t!!tt!*RtRtttRRtt tttttlttltR*!*tRttRRtltt*t*lRRt!!!Rltt!lRRttlRRltt <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: �E!,Q"lt_c c'7 <br /> Address: 3\ a 01 . Zip: S <br /> Phone#: <br /> Telephone: ( _)SZq"q(p Date Tank Removed- <br /> RlYRt!!!Rt!*!R*!!!!lRRRItR!!!t!ltRtRR!ltt;lt!*YttRlt!!tltttRRRlRl/ttflt!lttR!!ltttY*tltRY!!Y <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: — //�f✓/� � j��j�J Q J17� <br /> �/g'7Ed�QE1'C_ <br /> Address: <br /> Zip: <br /> Phone#• _ <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 /> !*ttlRR!!**lttttR**!*ltRtt**tRtttttt*t*!lttt*!lRttt!!tY**!t**ttlttltt*Rt**R!**tt**t**!*RR*! <br /> SECTION 9 - To be filled out and signed by an authorized represeetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name � G�e,/ , /0✓G- - <br /> Address: ^ SJR /14CL Zip: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *!*Y*tttltYttRtltltlt*tRtR*t*!lttt!*tRRltlRtRlttlttRt!*RttY!!*tRt!*tRt*ttttRtttltRt!**t!*!R <br /> EH 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TAMC PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />