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y <br /> I <br /> SAN JOAQ IU N LOCAL HMAI.TH IJS STRI CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet .vill 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: <br /> FACILITY ADDRESS: 3 (C [ f 0 — ;4 <br /> z��+ - <br /> TANK ID #39- <br /> xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx*�t*xxx�ix,c*xxxxxx <br /> SECTION - 2 - To be filled out by tank removal contractor: { <br /> Tank Removal Contractor: U o4 �) � / <br /> Address: 2./1 C�S.3/n S �i f Po/ 1 K PA ,-4 (/ ��Zip: 3 76 <br /> �— I Phone#: <br /> Telephone: Date Tank Removed: 119 S71 el <br /> xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: C <br /> Address: �6t 0� Zip: Y//// <br /> �/ <br /> Phone#: <br /> Authorized re a ntative f contractor certifies by signing below that the tank has been <br /> TECTIN <br /> d i an appy ed man as may be regal ed by Depar nt f Health Ser cps. <br /> VWPni <br /> SIGNATURE AN TITLE <br /> be filled out and signed by an authorized represnetative of the treatment, <br /> SI -sal facility accepting tank. <br /> Facility Name'Y-A <br /> tr— �111�� X760 <br /> Address: Zip: <br /> Phone#: <br /> Date c ved <br /> A H ZE SIGJA AND TITLE <br /> xxxxxx xxxxxxxxx xxxxxxxxxxxxxxxxxxxxx xxxxxxxxx xxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx <br /> EH 13 99 12/88 <br /> MAI LI G INSTR ONS: FOLD IN HALF AND STAPLE. AFFIX OPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />