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SAN .702%CjjIN LOCP,I� HF�i.TH�ISTF22CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> t:ttxtt:ttttttttxttttttt**xxx*****xxtxxxxxxxtxxxxxxxxxxxxxaxxxtxxxxxtxtt************t****** <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. The holder of the permit with number noted below is responsible for <br /> ensuring that this form i^s^ completed and returned. <br /> FACILITY NAME: �/�C� <br /> FACILITY ADDRESS: 3 2 / /YB✓L �'.7 dGl< TON C� <br /> TANK ID #39- - <br /> ttttt:xxtxttttxxxxtx*xx*xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxtxxxxxxxxxxxxxxt*xxxxxxxtxxxxxxxxxxx <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_W!" 5`7EItnJ m j2r S rof ' <br /> Address: 273. TZZPe� J%Z) vi S -ac Tt/Ny�fj Zip: _ <br /> __Phone#: <br /> Telephone: O 5�b'�(v�2_ Date Tank Removed: <br /> zztxzttttxtxxtxxx xxxx xxxx*xxxxxxxxxxxxxxxxxxxxxxxxxtxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxtxxx <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank <br /> Tank Decontamination" Contractor: 4 jL—S �-,� CTt2 X&/5- . <br /> Address: 2-7.3 TGA PEG 712-1Ve- ST0e/e7U/J[ G� Zip: <br /> moSZ01� <br /> 9-� o---.- .;- Phone#: �2aa i CclD�Li� <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 /> xxtxxttttxxxxxxxxxxxxxxxxxxxxxx*****xxxxx*xxxx**xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx*xxxxxxxx <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: Zia: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ttttttttttttttttxtttxxxztxxxxxxxxxxxxxxxxxtxxxxxxxxxxxxxxxxx*xxaxxxxxxxxxxxxxxxxxxxxxxxxxxt <br /> EH 23 049 12/88 <br /> NAILING 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 />