Laserfiche WebLink
• SAN JOAC�SN 'L0C�2�L. HEAL.TH�= S.TRI CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ***********************kkk****'*****k****•A'**'Y.**k*kk********k*kkkJkk**k*****k*kk*k*:tkk*******X <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 nermit with number noted below is responsible for <br /> ensuring that this form is completed and returned. <br /> BOURBON STREET PROPERTIES <br /> -- FACILITY-NAME; -- - -- - <br /> FACILITY ADDRESS: 1426 BOURBON STREET STOCKTON, CA 95205 <br /> TANK ID #39- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: W METER SERVICE INC. <br /> Address: 2735 TEEPEE DRIVE SU E. STOCKTON, CA Zip: 95205 <br /> Phone#: (209) 948-6124 <br /> Telephone,—(-209--- �--- 948-6124- Date Tank Removed: <br /> SECTICN 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination" Contractor: WESTERN METER SERVICE INC. <br /> Address: 2735 TEEPEE DRIVE SUITE E. STOCKTON, CA Zip: 95205 <br /> _ Phone# : ( 209 ) 948-6124 <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 /> X***Xk*X*****k***k**********k******:t*****X***:t:t*******A•*************X***kk*kkk**XkkX*kX*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 /> t; <br /> Facility Name <br /> Address: Zip: <br /> Phone# : <br /> Date Tank Received: E' <br /> i• <br /> ;i <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EN 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AIT'IX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT (, <br /> ATTN: UNDERGROUND TANK PROGRAM t' <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 i <br />