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SAN JOAQLJIN LOCAL HEPT•TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> xWWWW****xx**x****x*xW****Wx********W*W****W***W******WWW*W*********************WWWWW****** <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: �`%�� TQ c�t 'Cl �✓ G `��` �P <br /> FACILITY ADDRESS: ys�r r4 5���,�/ 95376 <br /> TANK ID #39- <br /> SECTION - 2 - To be filled outby tank removal contractor: <br /> '�L <br /> Tank Removal Contractor: qA /0eO,✓ �CfC.e06,— <br /> Address: o- 6c, K `l N C/C%yr c Zip: 5�'S32 <br /> Phoned: mac- X72 <br /> Telephone: ( ) Date Tank Removed: <br /> ***W*WWWx*****x*WWW**W*Wx*W*W*****x**W********x**x*WW************x****x**********WWWx****** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: QV�I�a a fl� F <br /> Address: X- a, Zo k Zip: � 2� <br /> Phone#: ?7Y- 3 2:z :;;, <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 /> SIGNATURE AND TITLE <br /> ***WWxx**********W*W*WW*WWW*****W***********WWWxxWWWW********W******W*WWx*****WWWW*W******* <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 SIGNATURE AND TITLE <br /> W*******WWx***W************WW*************************WW*****WWWx*****WW*****WxxW**WW*WWWW* <br /> Ell 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 />