Laserfiche WebLink
tMWj W,0UND TANK DISPOSITION TRACK INS. <br /> + yyyyyyyyy yy yyyL++yy ++ yyyyyyyyyyy yy y iy+yy yy yyy + y yy+:i '' yyyyy y + y <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. <br /> FACILITY N&4E*. (A141AA1 SCS - <br /> FACILITY ADDiiE.gB: M 6T I C <br /> TANK ID 139-- -)Ll I y . <br /> SECTION - 2 - To be filled out by tank removal;cor:tractor: <br /> i <br /> Tank gemoval Contractor: <br /> Address: w `� r�tJ� ric-# ^oLoD67S7"O CA Zip:' - s 1 <br /> Phone#: <br /> Telephone: { `� )_:�ti `��-5�—_Date 'Tank Removed <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> J <br /> Tank Decontamination" 'Contractor' . <br /> Address: _ .3) Zip: Th�35 <br /> Phone#: <br /> Authorized representative of contractor cextiikes by signing below that the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Service`s. <br /> SIGNATURE AND TITLE- <br /> SECTION <br /> ITLESECTION 4 - To be filled out and signed by an authorized represne'tative of the treatment., <br /> storage, or disposal facility accepting tank:" <br /> Facility <br /> 1 <br /> Address: O' SY LC Zip: <br /> Phone#: . <br /> E .i <br /> Date Tank Received: { <br /> i <br /> AUTHIORIZED :SIGNATORE .ANDTITLEri <br /> l <br /> Elf 23 049 12/88 1 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AWIX PROPER POSTAGE. <br /> SAN JOAQUIN LACAL HEALTH DISTRICT <br /> ATTN: 11NDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> i <br /> STOCKTON, CA 95202 <br /> 4GS-3460 468-3283 <br />