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SAN 70AgUIIV LOCAL HF'A r• DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 holde_of the ptrmit with nnmhPr noted <br /> ensuring that this form is completed and re erne ow is r soo sthle for <br /> FACILITY NAME: A '� ��YiA//T l ntiipan/y <br /> FACILITY ADDRESS: �}a/Q(� ( �lalFl? �F}�yP4�lF2L/-M Pra <br /> TANK ID 939- _ <br /> x#**k*************k***X#x*#k**x**X***kX**kX*X*k***x*****kx****k**#z**X*******k#******X***X* <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: i7 6 v ; C �- / 411 <br /> Address: p k�; c c v / -) <br /> Zip: h <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> *xx#*X**z**z*z#k*k*#***X**xk********X***#*k***X#**X**k**#X#****#***XX*kx*k#*k*#*xk*****k*xk <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: %v <br /> Zip: <br /> Phone#: c"7 > - <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 /> xxxxxxX*x*xz*z*#****x*xzxxz*#Xx*zxxzx*SIGNATURE <br /> X**D**z*TITLE <br /> xxz#z#kx*k*z*x**zxz*kxz*zx*zXkXX*x*x <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: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: �— <br /> "Lm <br /> *zz**z**X*z*x*#x*Xz#*xx*x*x*x#* kD**k#D**zUNA: UREAND**XzTITLE <br /> *z*X*x*XX#X#X*xxk*zkzXzx*Xzk*x# <br /> Ell 23 099 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 />