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SAN .70AA.0 S N :c..00"-zar• I-IEALTp*4 �r S.Tf2I CT <br /> r <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 memit with number noted below is responsible for <br /> ensuring that this form is completed and returned. _. <br /> FACILITY NAME: bra.... . kwjL ae-LL_ <br /> FACILITY ADDRESS: <br /> TANK ID #39- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: [.(l"-- eYv-. ✓ii1glr_ c 6'e'r. <br /> Address: X73 67 Tom- Pe-e— A je. 54oc kl5.. 0, Zip: <br /> Phone#: <br /> Telephone: Removed: <br /> 9 /we y <br /> ph �_) 94�.���_Da to Tank Removed <br /> ************7t***********i:****:t**�Y*:k******�l*:l:l******�Y****�l:l:l****:t*i.***:l•*******it***ic*****ir*** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: _ k� v-� V IC CY- 6LIC <br /> Address: Z?�3 + e O 12 5 4oc.ktVL_ C'e, ��S2cs" -Zip: <br /> P <br /> Phone#: W --if/g,—V <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 fITLE <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 /> Address: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> SH 23 049 12/88 <br /> NAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HE-ALTH DISTRICT <br /> AZTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> S=TON, CA 95202 <br />