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SAN .70AQ1LJI1-1 DI STF2�,�Q � <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> a�- <br /> xxxxzzzxxzzxzzzzxxzxzxxzzxxzzzzxz****xzzzxzzxxzzzzzxzzzzxzzzzzzzzzxzzzzzz�zz�zzzz**�, t '. <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompapfpcli tank <br /> affixed with its site identification number. The Tracking Sheet is to be ruY 1d 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: Defense Depot Tracy <br /> FACILITY ADDRESS: 25600 South Chrisman Rd. , 'racy, Calif . 95376 <br /> TANK ID #39- - <br /> zxzzzzzzzzzzzzzxzzzxzxxxxzzzzzzzzxzzzzzzzxzzzzzzzxzzzxzzzzxxzxzxxxzzxxxzzzzzzzzxzxxxxzxzxxz <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Zip: <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> xxx*********x**x**********x*******zh*************x**x**z****xx*****zxxzzzzxxxzzxxzzzzzxzxzx <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: Zip: <br /> Phone#: <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 /> zxxzxxzzzzxxzzzzxxxzxzzz**x***z*x*xzz*xxx**zzz*zx*zzz*x**x*zxxz**zxx*zxxxzzzxxxzzxxzzxxzzzz <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: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AU'T'HORIZED SIGNATURE AND TITLE <br /> xxxxxzzxxzzxxxxzxxxzzzxxzzzzxxzzxxxzzzzxxxzxxzzzxx******xXz**********z***xzzxzzzzxzzxxxzzzx <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 />