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1,0- <br /> 0 C`F i 6 19 <br /> 0-0G ; '_ 619 <br /> . SAN JQAQU2 N LUCAL L72 S'TFt2 CT <br /> cNViP()NMENTAL HEALTH <br /> PERMIT!SERVICE' <br /> UNDERGROM 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 ` racking 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. The holder of the. oermit With number noted below is responsible far <br /> ensuring that this form is com leted and returned. <br /> FACILITY NAME: ra C NS fZ a Fz ATS C <br /> FACILITY ADDRESS: <br /> 400 <br /> TANK ID 439- 1-14 - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: 1 Zip: 1?5 6q ) <br /> C.A Phone#: 16 - -_L73- U-7 -f <br /> Telephone• ( G► cp ) 27 - r{-� Date Tank Removed: dove a <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: VJ A L�;-b tl ��4„`s ED* ��- <br /> Address: 3'i e%t> L._Pil"%Z Zip: 5556 91 <br /> wsSr .'rr ra Phone#:(SLf._� J!-7 <br /> Authorized representative of contractor certifies by signing below thkit 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 /> Facility Name C i20tt. E ra 01 E'"f"-T- <br /> Address: Ri Zip: 9Sb-7 O <br /> N o acv L Phone#: 9Lb 35- <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> 7k*****7t**it*7t�t*:4*Itir**:t**�tir�t****ir7k�tirir****ir*icer**art*i;#iCir�tk**�':t*:t*ir***�C**91t;�ir:t*irir*kit***�N***k karst*ir <br /> Ell 23 049 12/88 <br /> ?MAILING INSTRUCTIONS: TOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL fEALTH DISTRICT <br /> ATTN: UNDMGROUND TANK PROC RAM <br /> P. 0.. BOX 2009 <br /> STc, CTON, CA 95202 <br />