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Sa�1N JOAQUIN LOCAT• HT;pT-TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> 4BCTION 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 comeleted and returned. <br /> FACILITY NAME: CfyEUZ�xf/�IJSf I <br /> (FACILITY ADDRESS: <br /> /TANK ID 139- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Z7O u �iPi�,r1,U c� ��r11'i�'TO/j/ Zip: <br /> � <br /> o lrox MW hone#: <br /> Telephone: cjo9 ) / �- /S� Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractoro ex <br /> Address: ��O v �4/7c�rlist� u�� Zip: <br /> Phone#: <br /> Authorized 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 /> r F_ t'Ev.•�i7 <br /> SI ATURE AND TITLE <br /> SECTION 9 - 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`SICNATURE AND TITLE <br /> 511 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 PROM M <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />