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SAN �7OAQLTIN LOCAL H'OAT rrH DISTRICT UNDERGROUND TANK DISPOSITION TRACKING RECORD SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to San Joaquin Local Health District within 30 days of acceptance of the tank by disposal or recycling facility. The holder of the ger it with number noted below is responsible for ensuring that this form is completed and return FACILITY NAME FACILITY ADDRESS: TANK ID 139- SECTION - 2 - To be filled out by tank removal contractor: Tank Removal Contractor Address: Telephone: ( ) Date Tank Removed: SECTION 3 -To be filled out by contractor "decontaminating tank": Tank Decontamination" Contractor: Address: Phone#: Phone#: P: ip: Authorized representative of contractor certifies by signing below that the tank has been decontaminated in an approved manner as may be regulated by Department of Health Services. SIGNATURE AND TITLE ****xx*x******x*****x**x********x***x*x*x*********x*x******xx*xx*xx*xx*****x**x*xx****x*xxx SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, storage, or disposal facility accepting tank. Facility Address: ip: Phone#: Date Tank Received: AUTHORIZED SIGNATURE AND TITLE Ell 23 049 12/88 MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. SAN JOAQUIN LOCAL HEALTH DISTRICT ATTN: UNDERGROUND TANK PROCR M P. O. BOX 2009 STOCKTON, CA 95202