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m 6t xix,L< <br />MAR 1 <br />ENVIRONMENTAL HEALTH UNDERGROUND TANK DISPOSITION TRACKING REcom <br />** e VIC <br />SECTION 1 - The San Joaquin Local Health District's Tracking Sheet wi31;''aecompany each tank <br />affixed with its site identification number. The Tracking Sheat. is to be returned to San <br />Joaquin Local Health District within 30 days of acceptance of the"tan' 'diposal or <br />recycling facility. a holder of he r i with number noted below i � <br />rd` ns able for <br />ensuring that this form is completed and returned <br />FACILITY NAME: UN®GPI.- _�- 6o O1 Cj' <br />FACILITY ADDRESS: &Ok 1 TIJEEML_�i Ae� L-O[7I , ('G <br />TANK ID #39- IZJ 1S - ®z° <br />SE)CTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: C.6tk� 40Ns? � ON <br />Address: 1_710 @ SFIEi_Q.- Zie: <br />L1 L 413913 Phone#: SC:5) 58'2 -5`1 0 <br />Telephoner ( ) Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />AELMddress:1-7 • <br />. •• <br />r <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 />SI "+IATURE AND TITLE <br />SECTION 4 - To be filled o and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Name <br />Address: <br />Phone# <br />Date Tank Received: <br />�! AUTHORIZEDMeNATURE AND TITLE <br />Ell 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROW%AM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />