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SAN .70AQLTIN LOCAL.. H Ar.TH DISTRICT <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 />FACILITY NAME <br />FACILITY ADDR1 <br />TANK ID 039- Unto } '1. 19bg <br />****************************************H�A fiH******** <br />SECTION - 2 - To be filled out by tank removal contractor: PERMIT /gEWICES <br />Tank Removal Contractor:L <br />Address: �J ,/ A �`� �ly�'l�S i�/c� (7 9,l 13 <br />Ph <br />__ one#:,, -S 8 T �7ee <br />Telephone: ( ) Date Tank Removed: /-Z4/ > <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: _ QCn f��tT/. iiC ��i cj�,ge&jjjl,Pld llA�/I <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decont"nated 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 />storage, or disposal facility accepting tank. <br />Facility Name /U�-< t� (,� <br />Address: 54 r v\ ✓ .f <br />Zip <br />PhoneO: <br />Date Tank Received: r Z / / I-- <br />(�')Cvy\- <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 23 019 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 />