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SAN .�'C.�AQU=N <br />UNDERGROUND TANK <br />1,0CZ, I.T1=I D= S'I'RI CT <br />DISPOSITION TRACKING RECD <br />SECTION l •- The San. Joaquin Local Health District Is <br />affixed with its site identification number Tracking Sheet will accompany <br />Joaquin Local Health District within 30 days of acceptance of the t �nY each tan <br />The Tracking, Sheet is to <br />recycling facility. T e holder of the days with number noted returned to San <br />�nsur tan by disposal or <br />that his form s com feted and returned helow is res Dons-1--b-le-for <br />--_ <br />CACILITY NAME; <br />FACILITY ADDRESS.- <br />TANK <br />DDRESS: <br />TANK ID 039- <br />******************�s o.ac� <br />SECTION -' filled 2 - To be. *****�* <br />out.: tank removal -contractor:. <br />Tank Removal Contractor: <br />Address*-*��' 2cS ✓� Z Kfi A. <br />Zip. �11 <br />Telephone: (ma 21 19'' Phone#:91 990 <br />******************************************Da*Ue Tank Removed.. <br />***** <br />SECTION 3 -To be filled out by ''decont*********x***�•******;��*** <br />aminating tank"; <br />or : Tat n <br />Tank. Deconta,nination'! Contract`C', r ._ r — <br />Address: <br />• � Zip: �SzAuthorized representative of contractor certifies b phone#:� <br />decontaminated in an.appzoved manner as Y signing below that the tank has bee <br />• �Y be regulated by Department of Health Servicers <br />s. <br />**GN * E**1INDkTITLE <br />SDCTION 9 - To be fil`led�out and signed b *x***************************** <br />'storage/'or disposal facility and <br />signed <br />tY an authorized repre5netativ <br />Facihity It <br />Name '"r vl." -� ,-,�, _ <br />g ank, a of the treatment, <br />Sol - <br />Address: <br />iG��F lvvr� Zip; <br />Date Tank Received: Phone#: <br />a <br />Ell 27 p 11112E AND TITLE <br />�9 12/88 <br />MAILING INSTRUCrIONs: TOLD IN.NALF.AND STAPLE.�� v* <br />AT•'F'IX PROPER POSTAGE. �{ <br />'SAN JOAQUIN LOCAL HEALTH DISTRICT, JUN <br />15 1990 . <br />A0: UNDERMOUND TANK PROGRAM <br />P• 0. { <br />BOX 2009 �NVIfONrvlEni�;�! ; f. <br />STOCi(T� CA 95202 <br />