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y UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SECIMON L - 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 Dermitvith nMMknf noted bel w in res nsible for <br /> ' eMurLn9_thdk tbisform is com2leted r J]%L- <br /> FACILITY NVe: <br /> FACILITY AMAWS: 7 <br /> TANK 10 t39-• � <br /> SE=10N w 2 - To be f i l led out by tank removal contractor: <br /> ' Tank Removal Contractor: 2111=2-475anr GO=' <br /> Address: j4 11,4C - • a Zip: 9507 <br /> Cg�YtaMj j 25&7 Fhone#: <br /> Telephone: { 2„1,c_1 � Oate Tanis Removed: <br /> ' SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tants Decontamination" Contractor: <br /> Address: <br /> Zip ..,..� <br /> Phonei: — <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 /> ' SIMfA'RJR£ AND TITLE <br /> x�r***x**z*xxx*xx�:*x*��**�**t****�cxx*xxxxx txxxxx�r*x*x*:xx*x*x*�******x*,t*x**xx*Yxxx�:�r*•**xtzx <br /> ' SDGTION 4 - To be filled out and s-igned by an authorized represnetatiLve of the treatment, <br /> storage, or disposal facility accepting tank. <br /> ' Facility Nane��,� _ •• <br /> Address; 4a, Zip: ' <br /> ' Phone#: <br /> Date Tank Received• <br /> J !4 r <br /> Ff <br /> IZED ,,IGNA, AND TITLE <br /> #t7tx7t:tyr:k** �zxx#7ktitic7ft***xyc*�l*a****,tyt*,kyt,t**�t����it7Yic�irk�t*fir*,tYrlr*�9C�Cytylric*k kirk** <br /> ' <br /> EX 23 049 32/88 <br /> AILING X?14STRUETIONS: D IN HALF AND SIMPLE• -r1X PROPM POSTAGE. <br /> SAN JOAQUIN IA= Ffr. LTH DISTRICT <br /> ATTN: UNDZMMOUND MIC PROM M <br /> P. O. BOX 2609 <br /> STocKTON, CA 95202 <br />