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S 7 C7 +QLJ I r o(=ALT., H .. rrH n x S r1TZ X C°T' <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 permit with number noted below is responsible for <br />ensuring that this form is completed and returned <br />FACILITY NAME: 7'0 , 02 igpl /12 <br />FACILITY ADDRESS: uvl, <br />TANK ID 139- <br />SECTION <br />39-SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: . lam ,y ® ow ®e <br />Address: 9, Zip: ur / <br />Phone <br />Telephone: (7of Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: w ,,,�,� A f <br />Address: _ Px ®Q.� G Zip:S� ? <br />Phone# : 2a y_ yCs- Zogoa <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 />SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility <br />t q <br />Date Tank Received: <br />AUPTHORIZED SIGNATURE AND TITLE <br />Elf 23 049 12/88 <br />14AILING 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 />STOCKTON, CA 95202 <br />