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L � <br /> SAN OOAQUT N LGL AL HEALTH DSS I'RI CT <br /> UNDERGROUND TANK DISPuSITION 'TRACKING RECORD <br /> xx*%x***%*fi*xxx*x*xfifi*x**fix%xxxx%xxx%xx*x**xxXxxx*x*x*x*rtxXXxx*%x***xxx*x*x*%%%%w%%*%www%%fi <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 Dermit with n�mtkr noted below i reso�natihi F <br /> ensurino that thiG form iG ray d re u <br /> FACILITY NAME: Nor-Cal Beverac:e <br /> FACILITY ADDRESS: 1800 <br /> .ic„ kr i C.ti <br /> TANK ID #39- 1LU4(5 <br /> ***%%**fi%*fi*x**x***xfi***fifi***%X*hxx*x**xx*xxXxxxxxx*XX*xrt*xXxkfi*%%*YtxxX*rtxwx%*%%%%fi%*wwwfi x* <br /> SECTION - 2 - To be filled out by tank removal contractor : <br /> Tank Removal Contractor:_,_,. ,_ .r. <br /> Address: P. ). Box 17�� r - <br /> Phone# ; 90 6 <br /> Telephone: ( }16 Date Tank Removed ; 916-652-5535 <br /> SECTION 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination" Contractor : c `_ "or sewn ce <br /> Address: P.O. 'Box 170 Lonrn, n Zip: 95650 <br /> Phone# : <br /> Authorized representative of contractor certifies by signing below ttkit the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services, <br /> SIGNATURE AND TITLE <br /> XXxxxxx**X*xxxx*xxx***xXxltxxxzkxxxR***xxx*xxxXx**'krt**x*xxkfi kk*kx*X*xxXrt*Xx*%**fifi%fi xfi*www*** <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 : <br /> Zip: <br /> Phone# : <br /> Date Tank Received: <br /> *kxGx Rx*x*D*xXLV*xT*RX ExxrNiDxxxTLxx**%xx Xzx*Xx%X%%*fiww%fix**www*%* <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 2005 <br /> STCCKTON, CA 95202 <br />