Laserfiche WebLink
S IJL _26 - 8_9 WED ,1 <br /> 1 S MOORE PETROLE�1 P 0S <br /> SAN JOAQLJIN T.00.AI. HE;n IrH DSSTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RWORD <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 Loral Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. TI1 holder of the permit with number noted below Ig responsible for <br /> erasmina that this form is completed and returnO, <br /> FACILITY NAME: r✓1>1'rU i-' 5 t X k0 1V -m q <br /> FACILITY ADDRESS: 141 8(2U r1,q- _1CA cg q-)7336 <br /> TANK ID 039- /tel; - <br /> *#**fi*kk**i*******k****k*#*X****k*k***i#****#*fik*X <br /> SECTION - 2 - To be filled out by tank removal contra tor: <br /> Tank Removal Contractor: C Gv�s/� � � � <br /> Address: -2 Zip: <br /> Phone9,, <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: Zip: <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 /> SIGNATURE AND TITLE <br /> SECTION 1 - 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: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> 81I 23 019 I2188 <br /> MAILING INSTRUCTIONS: MOLD IN HALF AND STAPLE. ArFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCXTON, CA 95202 <br />