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SZLW a0AQ1LTIN LOCAL, HEAL.T I/ DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> **W**********WX*******W**WW*W**W*****W******W*WW**W**W**WW*W****XXW**X*****WW*W****WW***WWW <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 form is completed and returned <br /> FACILITY NAME: ,:S q J q <br /> FACILITY ADDRESS: �2i - y,Q, . — �1.d S- <br /> 4K ID #39- <br /> PION - 2 - To be filled ouL i re100w ',l:cacCof: <br /> Removal Contractor: �i _ <br /> 10dress: d Sex N� 7 �5� r� nC Zip: RS3 �y <br /> Phone#: <br /> Telephone: ( `fy0�) 3 J-23 A Date Tank Removed: <br /> *W*W***W***W**X*****WW**W**W**W*W****W*W**W******W#*W **X***W**W*W*X***WWW**WW**WX*W***W*** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> 'rank Decontamination" Contractor: <br /> Pjidress: Zip. <br /> - Phone#: <br /> auLhorized 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 /> ***********WW***XW*****WW***XWk**WW*W**W**W*WWWW*WXWW*WW***XXWW**WW*WW**WX*W**WW*X********* <br /> SECTION 4 - 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: Zip. <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ********W*****W**WW**W*********W**********W**W***WXWW**WW**W**W******W****W*WWWWW******W**W <br /> EH 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 />