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T Cr <br /> UN RAO TAMC DISPOSITION TRACKING RORD <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. <br /> FACILITY NAME: S <br /> FACILITY ADDRESS: 1 ri L► Jl <br /> TANK ID #39- 2 r1 _ QZ_. 1 <br /> SECTION - 2 -- To be filled out by tank removal ,contractor: <br /> Tank Removal Contractor: <br /> Address: PIfl . a C--,►4 Zip; ys3 <br /> Phone#: <br /> Telephone: ( ) , Z " Date Tank Removed: <br /> SE7CTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: � � W. <br /> �----���`-���-sz---, Zip: <br /> Phone#:. LlsZ 3 <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 TITLE <br /> S=ION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name _ d <br /> Address: W. R c_A ILAcd6gsi o C �¢ <br /> Zip: 9�zf <br /> Phone#: 2.-Le�.2 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 23 049 .12/89 <br /> MAILING INSTRUCPIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICP <br /> ►TTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />