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SAN 0 02k 'SN 'LOHEP,T IrH DI S.TFLS 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: St . Josephs Hospital <br /> t <br /> FACILITY ADDRESS: 1800 North California etorktnn ra <br /> TANK ID #39- 163 & <br /> - is <br /> ********************k**********k•l:k*k***kkk****%•kk*k*******%'************k***k****k***k****** <br /> SECTION - 2 - To be filled out by tank removal contractor: S+N <br /> Tank Removal Contractor: <br /> Western Meter Service, Inc. <br /> t. <br /> n„. <br /> Address: 2735 Teepee Drive Sui ockton , A Zip: 95 0c— <br /> Phone#: ( 209) 948-6124 <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank" : �. <br /> Tank Decontamination" Contractor: Western MPtP,- Sprjjiro, Tnr_ <br /> t <br /> it. <br /> Address: 2735 Teepee Drive, Suite E Stockton CA Zip: 952os <br /> _ �!! <br /> Phone# : ( 209) 948-6124 t' <br /> Authorized representative of contractor certifi@s by signing below that the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> Wesley Dubose/ General Manager <br /> SIGNATURE AND TITLE <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. g <br /> �sT <br /> Facility Name r' <br /> i <br /> Address: !. <br /> Zip: � <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNA'T'URE AND TITLE y <br /> EH 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 /> 4 <br />