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SAN OAQUIN L.OGAI� HEALTH DI STRZ CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SECTION l - 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. Thg holder of the Wrmit with number noted below is responsible for <br /> ensuring that this form is completed and returned, <br /> FACILITY NAME: � 71�(�/CES <br /> FACILITY ADDRESS: YC Ir'/ !/t 1'rel(J C4 <br /> TANK ID #39- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal. Contractor: rZ,)e11 fiZTc1 J76WZV/66 <br /> Address: ZIP- <br /> S <br /> ip: 02 C <br /> �a -tv Phone#: <br /> Telephone: (2G! )_ ' 7 ^ J Date Tank Removed <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: L_- tC� L.v c <br /> Address: 2CA `f Zip: <br /> t c 0 0 L& Phone#:,LI�5-2 3 <br /> Authorized representative of contractor certifies by signing below ttkit the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <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 1C C ck sc,V1,\ t- <br /> Address: ('� rr yt3 Zip: <br /> l� Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Eft 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROQ:AM <br /> P. 0. BOX 2009 <br /> STO KTON, CA 95202 <br />