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0 <br />SAN -'OA.QU'I N LO<- AT., H T°H 13I I CT' <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 holderof the Dermitwith r t d l w Is-regggnsible for <br />ensuring that this form is completed and returned. <br />FACILITYNAME:- )OIJ-7 �� v <br />FACILITY ADDRESS: _ G?hsn <br />TANK ID #39- 73 <br />jr <br />- <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor:__,�),rLTiq/,zy��,�-, <br />Address:©GFX J ,,Tg2 rf�CD� Zi <br />� <br />. <br />Phone.#'¢ <br />Telephone: QM) 17T y-y33y Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: Zip: <br />Phone#: <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 Name <br />Address: Zip: <br />Phone#: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />EI! 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN • _L HEALTH DISTRICT <br />UNDERGROUND TANK PROGRAM <br />STOCKTON, <br />