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SatkIV JOt 2UT1V LOCAL HEALT DT STRS CT <br /> UNDERKROUND TANK DISPOSITION TRACKING RECORD <br /> x*z*xz*z*****z**x**z******zzzxzx***xxxxxx**xxxxz*xxzxx**xxxzx*xxxzxxzxx**xx****z***z**xxzx* <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 <br /> form is?completed and returned <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANK ID 139-- --CL_ x�� C� /i/✓� 3 �- ��s GJ <br /> xxxxzxxxxzxxzz*xzzxzzz**xzx**z**x*zz*x*xzzz*zzz***z*zz*zx*zxzxxxx***zzxxz**xxxxz*z*xx*zzxx <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_-_ '��` '///�®G(�� Q/Z <br /> Address: 3 S ��C/�lyl / �Q Zip: e- .2 4�2 <br /> / C4 Phone#: / <br /> Telephone: D to Tank Removed: /�/��Jc�J <br /> *x********x*************x********xx**x*****x**x****xx***xx****x**x xx** *x***x***x**x*x**** <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 prov era be regulated by Department of Health Services. <br /> SIGJA AND TITLE <br /> zxxx*****z**xzxz* xzz*x*xzx*xz*z*x*z**x*zzzzxxzzzxz*zx**xzzx**x*****zzz**xxzz**xxxzz**xx <br /> SECTION 9 - To be filled out and signed b* an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: 6 a <br /> AUTHORIZED SIGNATURE AND TITLE <br /> xxz*x**x****z****zxxzz***zxz*xxzz***zz**xz****zz**xzx***xxxx***x*z****x*z****zzzzz*xzr.*xzzx <br /> EH 13 049 11/88 <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 />