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aOAQLTIN LOCAL HlE2U.TF- r= SZ'R2 CT <br /> LMERGR D TANK DISPOSITION TRACKING RE;D <br /> A!rltitR*RitiritftititirititARRitRRRRhAR*RhRRitAAAR*A*A**AA*AAAAAARRftitAAitytA**hRRRRRRhRRhRRRRRRRRRirRRRA*hR <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 <br /> recycling facility.. The holder of the permit wi h nmber by disposal or <br /> notes hs+t nw <br /> ensuring that this form is comDt Pt F►ri and ,.et d <br /> r <br /> FACILITY NAME: , <br /> FACILITY ADDRESS: Ln r4 L Loc) <br /> TANK ID 039--L-3 <br /> ***********A�***Ahhh******AitfthRAAAAAA*AAAAAit>�A**AA**A*ft*A*h**A*Y�*RAAAAA*1tAARitAAAAAAAYtAYt*A <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor• �P Cts p <br /> Address: <br /> e Zip. J <br /> Phone#: <br /> Telephone: �Oq ZZ���i1�53 Date Tank Removed: <br /> **RR*****hRAh*RhRhhhRh**h*hR**Rh*RR*R*itARAR*A*hR***RA*RAAAAAA***RAi4hAA***R*R'itAAAAAA**AA*A** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: O <br /> Address: 3� <br /> Phone 0: <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 /> ************hhh*hhRRhitftithhhhhRRhRAR*AARYtRStARARAA****?tR*RARRAAAitARyritfrir*RA**R**RRRAAARAA*A*A* <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name rC\cso ��— <br /> T <br /> Address: 3 , <br /> Zip: — <br /> Phone Q: <br /> Date Tank Received: <br /> *Rhh*hRhR*h*h**h**Rh**AAhA*AhR*hhAUTHORIZED <br /> A*AASIGNATURE <br /> RRAND <br /> R*AttTITLE <br /> AAAAA*ithA*hAAh*hit*RhA*AitAAAAA*A <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 /> STOO(Tai, CA 95202 <br />