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SAN a c)o l ' I N L C7 C AL HE AL* . D = S TR 2 CT <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 permit with number noted below is responsible for <br />ensuring that this form is completed and returned <br />FACILITY NAME:_ <br />FACILITY ADDRESS: �c5� ��l O/\ ;pAa <br />TANK ID 139-_/ <br />SECTION -2 - To be filled out 'by tank removal-contractor:- <br />Tank <br />emovalcontractor:Tank Removal Contractor: <br />Addressi. Jr" 21qD 4\(F,. Zip: c1 ^8 <br />Phone# : 91 Lo 1) 99 a <br />Telephone: (��) 21 �� Date Tank Removed - <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank..Decontamination". Contractor: ��( S.C�(� 60t4s.7: <br />Address: 35?L.V5 Zip: tS' 3 <br />Phone#: 91(42! 199c> <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 />**ic*iF**********ityk.*irlfit***�!•***R*****************ic*iFk9r�c�C**********fit**********iciFicicic*ic*it :ric*ic***ic <br />SECTION 9 - To be. fil'led out and signed by a_n authorized represnetative-of the treatment, <br />storage, or disposal facility accepting tdnk,. ; <br />Fac i 1 i ty Name <br />Address:. ZS'S• rr <br />Date Tank Received: <br />zip: <br />one#: _ <br />15-) Z3s =13 C--3 <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 23 099 12/88 �, ��.►�,�.� <br />MAILING INSTRUCTIONS: FOLD INHALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT JUN <br />ATTN: UNDERGROUND TANK PROGRAM 15 1ggo <br />P. 0. BOX 2009 FNVIRONMENIAI IJI=.1 <br />STOC KTON, CA 95202 nrRp n,- ...... <br />