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r <br /> a'a <br /> �' ' <br /> HEALTH DSSTR="C.`"1' <br /> UNDEnGRO ND TANK DISPOSITION TRACKING Rk700F{D <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will arca:,, <br /> affixed-With-Its site identification number. The Tracking Sheet is to be returned <br /> etpau reach tank <br /> Joaquin Ltx:al:-Health District within 30 days of acceptance of the tank b dis r San " <br /> recycling facility. a halde or. he. r i wl by'disposal or <br /> sur n t s f form is cam feted a r u r t d w o <br /> FACILITY-NAME: _ <br /> FACILITY ADDRESS:-P--C <br /> TMMC ID 139-- Z _ <br /> ****a*s>t*a**>t**xarra�*�**�►**********�,�**�****�a*aa*art�.rta�***�****�**art*�#***rta***�rtaa <br /> SDCrION - 2 - To be filled outY tank removal - ******* <br /> b <br /> contractor. <br /> Tank Removal Contractor: <br /> • � � JC}Ill <br /> Address: <br /> Zip: <br /> Telephone: <br /> Phone 8: r� Cr 11 <br /> Date Tank Removed: <br /> D <br /> S - a�**#aaaa�r Cl' <br /> ION 3 To be filled out by contractor +i <br /> decontaminating' tank": <br /> Tank Decontamination" Contractor: <br /> Address: <br /> Zip: -�_ <br /> Authorized representative of contractor certifies b PhoneM: <br /> Y be <br /> decontaminated in an approved mariner as ma Y sign g below that the tank has been <br /> regulated b Department of Health Services. ' <br /> as**cart*�*aa*aaaa�*aaaaaaaarta*rtarta***�GN�*�**��*****>kaitarrx**�* <br /> SeCTloN 4 -- To be filled out and signed b **a******a*aa*****aa*cart**k <br /> storage, or disposaly an authorized represnetative of the treatment, <br /> facility accepting tank. <br /> Facility Name i <br /> i 5 <br /> t"' f <br /> Address: <br /> L �r- <br /> PharieBZiN �/ 390 1� y <br /> Date Tank Received: <br /> b <br /> ti <br /> >r>k*aa#a*a*a******rta*****a**arta* *{ ***D**a�*a*aa* <br /> �ATVIE AND TITLE <br /> AUTIEll 23 049 12188 <br /> MAILING ***********#**** <br /> INSTRt1LTiONS: M* LD IN HALF AND STAPLr ArFIX PROPE <br /> R <br /> POSTAGE. <br /> SAN JOAQUIN LOCAL 1EALT11 DISTRICT <br /> I ATItI; UNDIMMOUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> t . <br /> STOQ(TpN, CA 95202 <br />