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FACILITY NAME: /IJL <br /> FACILITY ADDRESS:J �/ //l MLeh f TANK ID { �U,drJ D q e� <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> This form is to be returned to San Joaquin Local Health District within 30 days of <br /> acceptance of tank(s) by disposal or recycling facility. The holder of the permit <br /> with number noted above is responsible for ensuring that this form is completed and <br /> returned. <br /> * * * * * * * f * * * * * * * * * * * * * * * Y Y * * * * Y * * Y * * SDLTICN 1 - <br /> To be filled out by tank removal contractor: <br /> �yr <br /> Tank Removal Contractor: Z61r S 2'erAl <br /> yrt Address• c) Z P e Phone # <br /> Zip 9 `i c� 05 <br /> Date Tanks Removed No. of Tanks <br /> SECTION 2 - To be filled out by contractor "decontaminating tanks)": <br /> Tank "Decontamination" Contractor <br /> Address Phone# <br /> Zip <br /> Authorized representative of contractor certifies by signing below that tank(s) <br /> has(have) been decontaminated in an approved manner as may be regulated by <br /> Department of Health Services. <br /> SIGNATURE AND TITLE <br /> SECTION 3 - To be filled out and signed by an authorized representative of the <br /> treatment, storage, or disposal facility accepting tank(s). <br /> Facility Name <br /> Address Phone# <br /> Zip <br /> Date Tanks Received No. of Tanks <br /> AL nnwIZFD SIGNATURE AND TITLE <br /> NAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX WP\TRACSFfr.LET <br />