Laserfiche WebLink
SAN JOPi�i.JIN L.00r,P,L HE'.ALT2✓ DS SIRS CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> x*****k***kkkk**xxxxx*x*z*Xz*k*xzxk**xkx***Xx*x*XX*xx*XzzX*zk*x**xk%kx*xkxxxk**x*xxxxx**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 permit with number noted below is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: (/-f�Atl G M�G�}RICJD ISl7�L 7 �O <br /> FACILITY ADDRESS: ( 3 Fj (>0176LB DN ST.. ST IcT ) j/ C14- <br /> TANK ID <br /> xxk*kx*******xx**xx*z*kxxxxx*xx**k*xXkxXXzzXxx**xxx*xX*zz*Xzx******xXX***zx**x***x*Xx**xk** <br /> SECT'ION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:. ;jtu /Vte 7-z� Std, VtCcy N cJ <br /> Address: iv <br /> T d57?7 ['/!TD/Y� C-4-- Z1 <br /> Zip: <br /> -AGZ2. <br /> Telephone: ( 9-aq )_IJ &- 6 /Z1� Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination" Contractor: Lt/�rjLG/j�� jgJj Scc2✓i /�, <br /> Address: Z_ 7 T �� -DRiye 9Tvck7w / cue— Zip: -f;-&5 <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 /> X <br /> SIGNATURE AND TITLE <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_ Z!2!A-,e l (�� (j(� <br /> Address: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *****x****k*x**k*x*xkkxxx*xkx*xkxxxx*x*xxxXxxXxX*kx**Xxxx*x*xXxk***xx**Xxx***Xxx*****xk**** <br /> EH 23 049 11/88 <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 />