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SAdV o(7AQUI111i LC)(: A2 � HMAL.WrH DISTFZICT <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 Gform is 111 comp„l�eted and returned. <br /> FACILITY NAME:- ]1 S CL� L7 kL C-0 6) <br /> FACILITY ADDRESS: 5 9-Ci E VT1 k_t(__i t� S lU-M A] GAI <br /> TANK ID #39- - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:— kc c_15 i b Pj (�_OL(S l �t L J /PIZ <br /> :address: _I D`11 5 . ��c�S i 11 I�(�n AOL '-�Ti DC.K.i 0Aj tri Zip: <br /> Phone#: <br /> Telephone: 61 CA I I Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: /`,!L6 el //tee IeI2 1_ , <br /> Address: _ ZED Zip: <br /> Phone#: <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 /> S 1 GNATURE AND TITLE <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 r' 0,.-) <br /> Address: Zip: <br /> Phone#: _» <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> irik�k*****itis*x*****�*��*******i<************�*****�**�r�t**�******�*****iric*�ksk�k*fir*�t�*it*it��ti�t•���:at <br /> EH 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. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />