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SAN J OAQUT N LOCAL IiEALTH D S S TR S CT <br /> UNDERGROUN'IrTANK DISPOSITION TRACKING RECOtM <br /> tank <br /> ***tYts*tt**t******Y*******z*xx*zx*xxzzzzxzzxzxzxxzzz*zxz*zxz*zzx*zxz*z*x*x*x*x*****Y*xYxxz <br /> SECPION 1 The San Joaquin Local Health District's Tracking Sheet will accompany each <br /> "affixed with its site identification number. The Tracking Sheet is to be returned to San <br /> SJoagoin 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 /> y <br /> FACILITY NAME: <br /> FL'CILITY ADDRESS: S. J7 <br /> ovv ��xd ) <br /> T111K ID 139 <br /> xl:�:zxYzzxxzxzx**Y**zzxzxxzxzxzzzzxzzz zzzxzzzzxzz zzxzxxzzzxxzzxzzzzzzxzzzzzzzzzzzx*xxxxxx � <br /> 'CTION - 2 - To be filled out by tank removal contractor: <br /> IrNG <br /> Tank Removal Contractor• L✓E �rN <br /> Zip: <br /> { . <br /> Address: STBckrO Gg Phone#: 42 of 9�R -i/yy� <br /> Telephone: ( ) Date Tank Removed: <br /> ::zrxxxzxz*Yzzz*xxzz**xzzzxzxxzx*zzzzzzxxzzzzxzzzzzzzxzzzzzxzzxxzzzzxzzzxx*xxzxxxx*xz**x**xx <br /> SD2TION 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination" Contractor: GIST ��� ' s�Z i/!C /N G . <br /> mress: 74� T2oaor �r Zip: <br /> Phone#: <br /> -r-,o <br /> i;uthorized 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 /> ��Yxz**Yt�*Y*Y**x***xxzx*zxxzzxxzxzzxxzxxxxzzxxzzxxxzxxzzxxzzzxzzzzzzzxxxzzzzxzzzxzzzxxzxz <br /> ;S=LN 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> c' <br /> :Facility Name <br /> Zip: : <br /> Address: - 'Phone#: <br /> i�te Tank Received:_ '- <br /> �E <br /> AUTHORIZED SIGNATURE AND TITLE t <br /> EH 23 049 12/88 <br /> ilAILING 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 />