Laserfiche WebLink
y B I ZS, <br /> odun Eh�' d �sr. <br /> Ste. J OAQU I N LOCAL HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> Sep <br /> *�/�1tax�vfirxtx*xxx**x <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet wil '� 6mpany 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 nota below is re,5ponsible for <br /> ensuring that this form is completed and rett *ned <br /> FACILITY NAME: o , <br /> FACILITY ADDRESS: C <br /> TANK ID k39- 1.24 k _ Q <br /> SECTION - 2 - To be filled out by tank removal contractor: 1 <br /> Tank Removal <br /> Contractor: <br /> Address: �"Je zi <br /> Phone#: 2 <br /> Telephone: ( a(,9 Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: �1��i �C� � ( �'� f —zip: G _ <br /> Phoneq: ,� -7 � <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as many be regulated by Department of Health Services./ <br /> SIGNATURE AND TITLE <br /> x*x*xx*xx**x******x*x*****x*******x*****************Wx*x*x*x****x****x*xx*x*x**xW**xx***x*x <br /> SECTION 9 - 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: C - `,C- vl G� zip: 5�` <br /> / <br /> Date Tank Received:__ <br /> *W***********************x*******WN()*R**xWD*W*GN**TU**Wh*D**xXL*W****x*W*****W*W****x********** <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br /> t <br />