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T <br /> ' Sr`iT`i ,3p�QLJ.+T r7 Lr�C�,L. HEA2..TH ICY S '� T GZ' <br /> tJNDE2MOLI (D TANK DISPOSITION TRACKING RECORD <br />' *��r:k**it*ycx71'xic**�cxYr:irx*itX*x*x*ic7tX*x**X�C*ic****7r*x*irir*xirxir**7r7t*xxXx**xx**7r7rxycyr*at**7rx**7t�lr#*71t�k*x <br /> SECTION l - The San Joaquin Local Health District's Trackinq Sheet will accompany each tank <br /> affixed with its site identification n=ber. The Tracking Sheet is to be returned to San <br /> Joaquin Local Health District within 30 lays of acceptance of the tank by disposal or <br /> recycling zacility. The holder of the permit with number no below_ig re- <br /> e s x"n tY t this frm s ori leted and re`ur <br /> ' <br /> FACILITY NAME: Glenbriar Estate <br /> ' FACILITY ADDRFSS: 27383 MacArthur Road <br /> TANK ID #39- <br /> *x�ztitxx*xx*Xr�kxX**7tirx�kicxt**7rxx*fir***ic�7Y7C7C-t*xx#fir**7tx*E*icier]t:t*7l*7tr7t�txii*xx7ex�cX7r7Y7[*-kx**irxxir#***#ir <br /> ' SF=ION - 2 - To be filled out by rank recroval contractor : <br /> Tank Removal Contractor: Amer3.can Fnvzronmental Management Corp. <br /> ' Address: 3719 Lincoln Village Drive, Suite #501 Zip.. 95827 <br /> Sacramento, California 95827 Phone# : 916) 364-8872 <br /> ' Telephone: { 916 ? 364-8872 Date Tank Removed: <br /> 7tiea7C*yr�lc*fr:t#irlr7rx;rx*7��C*x*ir7t*xirxxx*x*�x7tx�e7t k*7t�t*stat**ir*X*xyrx*xxxx7rz**�rx7r�r7t*YtxxxxxxxXx�C7CX7r*x**irk <br /> tSFXI'ION 3 -To be filled out by contracto= "decontaminating tan?.": <br /> Tank Decontamination" Contractor: <br /> Address: 21p: <br /> Phone# : <br /> ' Authorized representative of contractor <.-ertifies 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 /> ***7f*9CyC*'YXx*><x%xit*xyCyC�C'k�irx**7cleXirk7kx�rxxxx t*#'*t*xxickxycyCxyc7ex7�7r�7t*laic*ir*yc7r7r:ryCie7r7tieicx�[7t*x7txx71f7[yeyr7r7C <br /> =10H 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> ' storage, or disposal facility accepting tank. <br /> Facility Name__��1C <br /> ' Address, s Z <br /> cis t Phone#: / • <br /> ' Date Tangy. R!ceived: l/ <br /> AiII'E oRIZED SICNkTURE AND TITLE <br /> ;tyrX**7k�*i-irx� x 1�sA14 <br /> Ett 23 fl49 17188MAILING INS':RL�CTI0 5 FON F_U.F 2UND STAPLE. X. IX PROPER POSTAGE. <br /> JOAOUIN LCC:--L HEALTH DIS'IRIC.T <br /> .kT'IN: UNDj_NG=ND TANK PROGR M <br /> P. 0. KX 2009 <br /> ST=TbN, CA 95202 <br /> _Iii] 1 3 111=1dJ L� <br />