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6 <br />S.AL`Y aOAQUIn y oc0z� Hy_i, T ,rH lD3 STRI CT <br />UNDERGROUND TANK DISPOSITION TRACKING REODRD <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 Loral Health District within 30 days 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: V)r) )-AC, 6 j ,, IQ it; <br />FACILITY ADDRESS: S -- <br />TANK ID #39- 1 'A _ y <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: V1 (:\ L- , Cc, } rA <--,i. it t ,r c I ) tt\-i --- - - - <br />Address: A _ �S � 1 �J C1 L U ` 1 j . _ S'�"ic�,A Z ip : � ( � C <br />T <br />Phone # C1 j .j k l r <br />Telephone: ( ) Date Tank Removed. <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: <br />Zip: <br />Phone#: <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 />S I C24ATURE AND TIME <br />***Mciclt9c********'kir*ic****Yt�c****YCK"*iCyt*�[Yc*x�c*Yc* is**7t'kip'kxYc**icJ(*7C'k',t;k*Yt***yt7t**YC'k*�t*YcYr9c*Yr�c*YCYk�k7t*7t*�iC <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 — <br />Address: <br />Date Tank Received: <br />Zip: <br />one#: <br />AUTHORIZED SIGNATURE AND TITLE <br />Yc7k*****Yr 9C�f**�k**�F*�k*Yc�F*7k�c�:5k*1Y]k*71c*%*�Clksk**i[*7k 7kic7kYCKis7k7liCiKkiC�k:tA'*kX5k7k�k9[Yt�k'*7kx�yf7t**Y2�kx*k�[*Xi�•y:�4•*:Y�t•5k*7k <br />Elf 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFF1X PROPI+:.t POSTAGE. <br />SAN J•OAQUIN LOCAL HEALTH DIS'T'RICT <br />ATTR: UNDIMGROU14D TANK PROMAM <br />P. 0. BOX 2009 <br />S'I'O�wv, CA 95202 <br />