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S�3L`r JC7AQUI N LC�CAL� HF'-ATsTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 gays of acceptance of the tank by disposal or <br /> recycling facility. The holder of the permit with number noted below is responsible for <br /> ensuring that this form is completed and returned, <br /> FACILITY NAME: 'r. +2 L1 <br /> FACILITY ADDRESS: 9 / � - 7,1A-1 I C4 'ADO <br /> TANK ID I#39- - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: S- TZ -0/e7-6.o <br /> --- <br /> Address: `J <br /> Ta AJ phone#: <br /> Telephone: (,;2-6!{_) 6 `{ � Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: LC� C�ryA cr. <br /> Address: (` Zip: <br /> .1) Phone#: Nom,-2,3L( J <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 /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> u.1^ <br /> Facility Name 1G f' t c�t -,c, <br /> Address: - ('� LYf) Zip: <br /> o Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> SI[ 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE.. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGt2AM <br /> • P. 0. BOX 2009 <br /> STOC'i.(TON, CA 95202 <br />