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S.ANf .�OA,QU'Z N L CD GAL SAL T H D� �TR I CT <br /> UNDERGROUND 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 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 responsible_for <br /> ensuring that this form is comipleted and returned. . <br /> FACILITY NAME: u_ Ce 5-TAM aU - <br /> FACILITY ADDRESS:_ 1 D"I I Y1c.,►� 5� � , ►'�°�*-�-r�c ---- <br /> TANK ID :939- <br /> S E)C�r ION <br /> 39-SECTrION - 2 - To be filled out :by tank removal contractor: <br /> r <br /> Tank Removal Contractor: AN Z rani=-2- Qya_Ma� <br /> Address: Is 01 -Zab .mut; - Zip: <br /> :c)4s <br /> �- •/�, Phone# : �4 6S) X31-43Sc�1 <br /> Telephone:, la S-0 i Date Tank Removed:. <br /> SECTION 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination". Contractor: Aa rz­ [� � _ �`55cXia`f5 <br /> Address: i lal- 3 +•/L Zip: C)46% <br /> 1�I CA Phone#: 1S 3 T r3Sc�) <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 /> SIGNATURE AND T I TLE . <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal: facility'accepting tank. <br /> F'acility..Name_ lyli5c� 1�1 --- <br /> Address: ? I� .rZ �1vD Zip: 9.481 <br /> Phone# : <br /> Date Tank Received, - <br /> AUTHORIZED SIGNATURE A14D TITLE <br /> �***** k9c**iek9t**�F*�k��e*�k�k7k*#**k*iCiC4c**9ck*kYsk**7k****�C7k�Y�]F7�5t#*�Cat�sieiF��i�9C is it 3e YC*i[*�: k 7F**#�9G9:�t:k�e�k:k7k*k9r <br /> 311 23 049 12/88 <br /> SAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. A-1-FIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TAN ' PROGRAM <br /> R <br />