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SAN JOA -T1 W LOCAL f-1Fn =FT DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *lrrxx:lxttrrlr:*rrrrrxxxxr*l:rrrlxrrrxxxrlxxxt!lrxxxxxltxlxrlr!!#lxxrrrrttlxtx*r!!rrl:rrr! <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 facili/ty//. The holder of the permit with number noted below is sWnsible for <br /> ensuring that this form Is completed and returned, <br /> FACILITY NAME: 01V/ ✓ S44-, afq n L�_, J eP <br /> FACILITY ADDRESS: cI J`'U //V 10 LJ 7-9/A-t- <br /> TANK ID 139- <br /> x!!!*!*r!t!lxrrt!!!!!!!**!t!t!!R!!!!!r!lttRRRRt!!R!R!lxtr!!*!x!!**!!!!!!!xr*!x*rrt*tr**xr** <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: '�2`x\c (n <br /> Address: y3\ \k) - \'\ cCn Zip: S I <br /> ma- �aPn , c Phone#: <br /> Telephone: (a-)' )S-2-q'q(D5-3 Date Tank Removed: <br /> rxr!*!rr!*rxrr!!rr*x!**x*ltxxrrxrxxrtrxrrlxr**xxlrrlrtlxx*lxxrr*xlrtxlr!!rr*x!!:rlxr*xxrlxx <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Sp_m( d <br /> Address: � I L0 �A� IA � Zip: S <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 /> *xx*xxr!!!x*rxxrlxlxlx*!*r!!!x*r!!xxlrrrrx*!r!r!!trlxxxxxlxrrxx!!!!lrxr!*!xrlx*lrrxlrlx*!!x <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: L13 Lk- . IALX�( In 41�a • Zip: X535') <br /> lN\'n,Io )h FI CA Phone#: r�i�- (ice nSS <br /> Date Tank Received: <br /> AUTHORIZE) SIC3NA71JRE AND TITLE <br /> xxlr*r**r!x!**rlrr!!lrrx*!!!!x*lxrx*!xlxlrx*!xr!!*xxrx**!xrlrx!!rrlxr!lrtrlr**!!!rr!!xxlxrx <br /> EH 23 019 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND 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 />