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SAN .JCDAQU2 N LaCPT. H:E-art•TH Imo=STR=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, Tb!�.bolder of thgpgrmitwith Doted bel!2w .i5 resV2D§ibjCor <br /> t rm om leted and retgrng-d. <br /> FACILITY NAME: ':� d A •��� �� <br /> FACILITY ADDRESS;, 1���1�7n.rJll S7' �' !?.;f•�i-�t> -- <br /> TANK ID 139-- 140'76 -- - <br /> xx**�*xx*x*xxxxxxxxxxx*x*xx**x�**�*�*****�*xx******xx*x******�rx�rs*�*x*x**xxx�r*x**x�xx*xxx*� <br /> SECTION - 2 - To be filled out by <br /> by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: 7�� .Qc� r l��a �r9 Lj� - zip; 3� <br /> Phone#: ^ <br /> Telephone: { ) Date Tank Removed: /� 4 <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> •.nk Decontamination" Contractor: ����P �- aJ7' <br /> -� -- _ <br /> Address: T�� �x�C !�` -Zip: <br /> �_`,r4�iy9 <br /> Phone#: d Z <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 /> i " <br /> r� r ` <br /> S I C24ATURE AND TITLE <br /> xitx�x�xxirx**x***xxxxxxxxx�rxxxx xx***xxx*xxxxx�x***xxx*x**x*x**x*xa**xx*x*x*xx*******x*x�*** <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 /> J <br /> Address: 0130-,0 w Zip: _D <br /> Phone#: a - <br /> Date T44 Received: <br /> 11L j A-.,t-.e- <br /> AUTHORIZED SIGNATURE AND <br /> �f 23 049 12/88 <br /> ►ILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. Ar'FIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL [MALTH DISTRICT <br /> ATTN: UNDMC ROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOC KTON, CA 95202 <br />