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SAkj .JO oul iq T Ocl L, f3F_..H.L. D = S'i'FZ X= <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 Derma with number noted below is responsible for <br />ensuring that this form is completed and returned <br />FACILITY NAME: L I-J06P-L <br />FACILITY ADDRESS: <br />TANK ID #39- 1_34 <br />- <br />-. <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: a�g� �l�l� �-i1 24 <br />Address: 110 LoW&V S7Zi : 93612 <br />Ll 413913 Phone#: �BG�)58�-55'%0 <br />a <br />Telephone: t ) Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: W E;/ZE ET �pN �'C�UG"T1 Dt�l <br />Lj i <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated/i 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 Name <br />t_. <br />Address: ' ��� �'�t C zip: <br />Phone <br />Date Tank Received: .20 <br />11 A ,n a® t <br />�✓ AUTHORIZED ATONATURE 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 PROGRAM <br />P. • BOX 2009 <br />STOCKTON, CA 95202 <br />