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SAALN ..7(DALQU T I�j T C)C A&� H]E2 .L,TH %)I <br /> _. 7 121: <br /> UNDERGROUND TANK DISPOSITION TRACKING REOORD �: : �AL Hfi-ALTII <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 by disposal or <br /> recycling facility. The holder of the Permit with number noted below is res onsible for <br /> ensuring that this form is completed and returned. <br /> FACT L I TY NAME: A2-I I C lv(�o <br /> FACILITY ADDRESS: <br /> TANK ID #39- / 76-7__ <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal. Contractor: 7 2-k <br /> Address: -32 iia-"2�1�+��tl r. �2£ Zip: 613 Z7 <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: i�3 'L- _AC_.ojo L� <br /> Address: Lo w{ e ` Il � �t'�J�1 1 X7 4 A l .' fG?'� 8A-Zip: 3 3 <br /> Phone#: f22�j- 393=_5-77c.) <br /> Authorized representative of contractor certifies by signing below thc1t the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> *�C*:k*k•Ys**at*YtYr#ic*�:#Y�*#�Cirlr#�ks�#*#ikrk�•#*##;k##**�r�kYc**ic*k#%"k�'#ak*&*:[*#Yr*##•k;k**k�kik#�e�k'k�cirir#***�k###�C*# <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility ,ac}cepting tank. <br /> Facility Name_ W ELER - � A4--j L <br /> Address: _Zi <br /> - Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *%'*######�k######*�t#Yt�r#'*#*�';*'rk'#ak*#*:kyt*#�C##�kY;#####rk###ir#4##h�•**#ik�'y4�k#ilk#�Y###y�##sk#*#�t�•#kYt*k#sk�E'�k <br /> Ell 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 /> STOCKTON, CA 95202 <br />