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S1 N .J__O—A—QlUIN LOCAL, IIEALTH�ISTRIC-r <br /> S ND TAW DISPOSITION TRAMING RECORD <br /> !*k!k!x!*!x!k*!!*!k!***!*xlxR!!x!!xR!!!xR!!!lRxx!!x!!xk!!RlxR!lxRftRRARRflR!!R#RRRRR!lxkk!!! <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany <br /> affixed with its site identification number. The Tracking Sit la to be 'rrto Sart <br /> Joaquin Local Health District within 30 days of acre <br /> recycling facility. The hold Ptance Of the tank by disposal or <br /> er�ur{na ►.= rmit wi h n*"►�r notzetUZ� _t �t. <br /> et W—L&IRAMBILbUlt <br /> ._.t this rrfDDorm is st <br /> FACILITY NAME: }�j�ryvAp_'q t4A'L' <br /> FACILITY ADDRESS: a7S o44/ y na r. KM Ok'2fn 0A <br /> TANK ID 039- 7 <br /> x!*!*!*x*x**!!*k!x!R!x!x!x!!RlxR!!!xxlxxRlxRRR!*!*RlkR!!!!!!!!!xR!!xR*RR!*lflxk!!k!x!**!xk!* <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_ F" GQ <br /> Address: 1 6a <br /> 1Mr� aFcm� q � , � Zip: Y <br /> Phones; C1A <br /> Telephone: ( ) Date Tank Removed: <br /> !x!*!tF!*!!!xx!*!*!x!k*xxkxk!*xklRlxxlxlx!!x!!!x!x!!x!!lkRlRlxkxxl-Rl-Rlx!!!!x!lRlxx!!!lklxk <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: /���/!Y) <br /> Address: <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 /> !!x!*****x*x*!x*xxlx!*!t!!x!!!■!!!!!!l�GNMlAAAM,EtlAxlMllTITLE <br /> lx!!!!!*!lxxlxlxlxlxk*!kx!!x!!!!k!!x <br /> SECTION 9 - To be filled out and signed by an authorized repreanetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name U/`lam <br /> Address: 3 Zip: <br /> Phonte0: ��-�=Lc� <br /> Date Tank Received: <br /> !*!!*x*!x*x*!***!*R*!x!*!R*!*x*!*v fktlkl�lx6ILMAlTUREx*AND <br /> !!k!TITLE <br /> !x*xxxRlxRlx!!x!x*!x!!Rlxlxxxxx <br /> EH 13 049 11/88 <br /> HAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATiN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKT Nr GA 95202 <br />