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v Vii V� ftwjky rrH Dicer Ri�ri <br /> TANK DISPOSITION TRACKING MOW <br /> !t*!!!!!!*!!*!33!*!!!k!!!!tklk!!!!1!!!!!!t!!!!!!k!!!k!k!!!!!!!!!!!!!!!*tkkk!*!k!k!!!!k!!!!3 <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 <br /> recycling facility.. The holder of he permit with nLh°r nota' by disposal or <br /> ensuring that this form is 1 ted n r tur low is responsthip for <br /> FACILITY NAME: 40(:4 no lam/ (�(� �� n U ��S TC T <br /> FACILITY ADDRESS: 1 1 O 1 1 4V")y D O 1'1lA-),JTE C9.5336 <br /> TANK ID 139- ')-2 59 _ <br /> !****!t!!3!t***!tt!!*!!1t!!!!*!!!!!k!!!k!!k!!!!!!!!!lktklklk!!1F!!1t!!!!!!k!!*!!3!lltl!!!!3!!!k <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: ZSP'Ct_b <br /> Address: 1 C <br /> Telephone: (coq 6Z1-1- R-053 Date Tank Removed: <br /> ***t*t*****tt*****t***t!!*!k!!*!k!t!!t!!!k!!!k!!!t!!!t!!!!!!k!t!t!lkkkk!!!!t!!!k!k!k#t!k!!t <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: lC\( O <br /> Address: —zip: 9s <br /> Phone/: jcj_(j(nS� <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 /> SI <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 �NK_11C C7 <br /> Address: 3 . <br /> PhoneYZip: <br /> q� <br /> Date Tank Received: <br /> **!****!!*!*****!*3x3!!k!!3!!!!!A kUTfOk:lED!!!!�!'lkTURlk*!AND!!!*xx <br /> EH 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 PROGRAM <br /> P. O. BOX 2009 <br /> STOOCTON, CA 95202 <br />