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UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />****ir*iC****7ti**f'*�'k*�CSti::t9c;t'*rk:t*sl'A-s4'i'/:;i*A':kl:'A'!:'R'k1:9r1'iY'X�'rYA�l i;�tYA'*tAi:Apt'�:t%•:1'l**i'isz;Fye'i::ttz:l•ir:Y*yF**yc**i:*fit <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 Focal Health District within 30 days of acceptance of the tank by disposal or <br />recycling facility. The holder of the perm.it with number noted below is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: <br />FACILITY ADDRESS :f3 oCQ I t <br />TANK ID #39- �`' - �� U� 000 <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: fi r^➢ ;l1 efL�' 5 _ <br />Address: <br />zip: <br />Phone# : '4 Biu l Z> <br />Telephone: (v 017)�V,5_Lf 2y Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": - <br />Tank Decontamination" Contractor: =�e r _ C-'4-6//( Ir e _7 � <br />Address: <br />£_ <br />one :- <br />Authorized representative of contractor certifies by signing glow that the tank has been <br />decontaminated in an approved manner as may be regulated by Department of Health Services. <br />- _SIGNATURE AND T I TL.E <br />R*ir***ik#*****x****ir*�:*******ir�tii**,ti:k�tA*7rX"�:k/cAkk�1`kkYrAk9t*�;is�l#i'Xti:'*k`7t9tk�cX'*7r*�l'***7: i; i; *7Firyt*ytycic*zkic <br />ISECTION 4 - 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: <br />to Tank Received: <br />Zip: <br />one#: <br />AUTHORIZED SIGNATURE AND TITLE <br />ir7Yik7kir*�***t.**Sk***3:fir**kirAirakakiri:i:*i.'isAxkali;;kil9r:kR•lcici:/C:k7l•irA'kXSkkkA*X'X•i'A****i:hiririr*7k**71 :i 7k A'*7l'7l•ak4r**]kirk* <br />23 049 12/86 <br />LING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />AWN: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />