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SAN JOAQUI N LOr�aT• HEA]�TH L7I STF2I CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> ffixed with its site Identification number. The Tracking Sheet is to be returned to San <br /> oaquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> ecycling facility. The hQ1der gE the perffilt-with number noted below ie *asoonslble for <br /> naurina that this form is com_nleted 5111d returned._ <br /> ACILITYNAME: TRf�� �l �FFI i <' r nED `T <br /> ACILITY ADDRESS: ISS ^� LjC_(-A CP-, <br /> ANK ID 139- 4573 O - �r <br /> ECTION - 2 - To be filled out by tank removal contractor: <br /> ank Removal Contractor: S;-kc( <\ S v a c E STATl0(1 F e n c - <br /> ddress: <br /> ;�G v (1 �T. Zip: <br /> 5"rc)04-r— t Cr1 Phone#:(�c 6� <br /> elephone: ( ° 1 ) C,LA -c� .33.E Date Tank Removed: <br /> ****}k*x**x}k****x******xx*}***************k**}*x#**x************************************* <br /> ECTION 3 -To be filled out by contractor "decontaminating tank": <br /> an" Decontamination" Contractor: V— f-ic_\tiScn <br /> ddress: SS c L V i1 Zip: q4 Rt I <br /> C{�L l p Phone#: 4IS-- 23 .N- 13(13 <br /> .uthorized representative of contractor certifies by signing below that the tank has been <br /> econtaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> SECTION 1 - To be filled out and signed by an authorized represnetative of the treatment, <br /> itorage, or disposal facility accepting tank. <br /> 'acuity Name <br /> ddress: zip: <br /> Phone#: <br /> )ate Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> kk}}k*}kRk#*tk***#*kt**}*******}*x*k*k**##k*#**#}#**k**###kk#*#**k#kk*##****k*****k*k**k*** <br /> ,H 23 019 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> AM: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />