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S.Ai�lf J" OAQU= N L OCA�t, HEAL, TH D 2 S TR 2 CT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />SECTION'l - 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 pgrmit with number noted helow_is r — risible -for <br />ensurino that this form is completed and returned <br />FACILITY NAME: <br />FACILITY ADDRESS: <br />TANK ID #39- <br />SECTION 2 - To be filled out by tank removal-contractor:- <br />Tank <br />emovalcontractor: <br />Tank Removal Contractor: `T�( A��i C-m(E C'4nNfT.j', <br />Addressi <br />\(I✓ . <br />-Zip: <br />Telephone: (cl�) ate Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank..Decontamination" Contractor: AA ( � " -_(--- C>`4.57. <br />Address: _ �j�jZ 5Z kLD .AVS <br />Zip: Sj2�j <br />T� Phone# : 91 t9 421 199 0 <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 />��****ik***�**�*�FYc.�*******�****�*A•�k*****>C*9c**.�C**ic*k**�C�C�****ic**ic****Xic�c*Yc�F*;kk*ic**;�*it**�c�c�cic*k <br />SECTION 4 - To be filled out and signed by a.n authorized represnetative.of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility. Name _ 'r 4A-NV�(,e_ _ GCS ,t &T. <br />Address: X525 �2ti1�, P*�lE. <br />5�ivl n1T1 zip: <br />Phone#: `IIlv3?f2.57a <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />�cYc9c**�9c4c****Yc�k�t�Y�t9t�Y*�k)k.�9c*�Y4c�k�t�k*Yr**��k�kir***�k�k9ck*�Y�c*�k*��k)k*�tYcic�k*4c 9c*�k��F�c 9c 9c 4c�k�Y*k�k�*3c�k9c*ic�C�r*�kk4c�*9c <br />Elf 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN,HALF.AND STAPLE. AFFIX PROPER POS <br />TAGS. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />