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J <br /> UNDERGROUND TANK DISPOSITION TRACKING REMPQ <br /> #***aC*****##yratat:tatXX*>t****#X7tatatytXXat*Xatatat*ytt*at#atYYYxX7CX**xXat****XarXXnxxat****YX7tY7C#******#*ataY7e <br /> SECTION 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 clays of acceptance of the tank by disposal or <br /> recycling facility. The holder 9f the rF--rmitvith n2Mt&r noto below ia rg§22rislble fo <br /> e sir tm_tt�'�t Lhis forge,.Ig Completed and returned, _ <br /> FACILITY NAME: <br /> FACILM ADDRESS: 2Z38'l XQ=thur Road <br /> ' TAW ID 439-� <br /> atat�r*�**aratt�*���*:�kaharat:t�rXi:*xat�*��*akamaf:ar7tab�******XaC>t#***atm*****iratat#at#at:t:CX*arm**�*Yx7PXat*****�*�*� <br /> ' SECTION -- 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Aa-rjran yjMdX=L4a_utal Managmal go - <br /> ' Address: _ 0719 Liranln viuAvg 1kXxva. Svc zip; 95827 <br /> ZACXAMe71rn. A.1 fo is 95822 .. .., _ _ Phone: <br /> ' Telephone: (1Date Tank Removed: <br /> xtxx*irakatatatiru�ratrxat�tat#atita**xsf##**#Yx�r*:�xxxXX*x�c��tt*txxxx�ttX�t*xxx*****x*�r*x******X*XXxxx******x <br /> SOMON 3 -To be filled out by contractor "decontaminating tank": <br /> ' Tank Decent'c-rmination" Contractor: <br /> I <br /> Address: Zip: <br /> IPPhone#. <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 /> ' SICNA`.d M AND TITLE <br /> *at Tc at*ak*7tytYc*7t at**xatx*xataY#*xaatatxaex*atx*##xxxx rxx�'atxxat7rXatXxatXatXarxir*aYar*atYcat*at*#**#xxxx>ex***atatatakRXx <br /> SECTION 4 -- To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tzink. <br /> Facility Name EE C�= <br /> Address: S 4ttg- Zip. <br /> Phone#: <br /> Date Tank Receiv � <br /> k� c <br /> ANK ORIzED siGNkTURE AND TITLE <br /> ' atxaeX*it*>tat*x*xirt## tD <br /> £Jf 23 049 12!88 <br /> MAILING INSTRUCTIONS: IN HALF AND STAPLE. ArFIX PROPER POSTAGE. <br /> ' SAH JOAQUIN ELML HEALTH DISTRICT <br /> ATT.'N: LNI)EMOUND TANK PROGRAM <br /> P. a. BOX ":1449 <br /> STOCKTON, CA 95202 <br />