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SAN .JOAQua:N LOCAL FimAr.TH I72S7TZICT UNDERGROUND TANK DISPOSITION TRACKING RECORD xxxzzxzzxxxzxxxxxzxzxzzzxxxzxzxxxzz*x*xx****xzz*z**zk*z**x********zxxxxxxxxxxx*xxxxzxzxxzxx SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to San Joaquin Local Health District within 30 days of acceptance of the tank by disposal or recycling facility. The holder of the permit with number noted below is responsible for ensuring that this f//or//m is completed and returned FACILITY NAME: FACILITY ADDRESS: TANK ID #39- / 70 ****x**********xxx***xx*******xxxxxxxxxzzxxzzxxzx xxxxxzzxx **zx*x***xxxxzxxxzxxxzxzxxxzzxx SECTION - 2 - To be filled out by tank removal contractor: Tank Removal Contractor: P/c Address: /�D_ jQ„k .7,076 IA Zip: Phone#: 2�r-YbS- 2COp Telephone: ( ) Date Tank Removed: ****x*xxxxxxxxxxxxxxxxxxxxxzxxxxxxzxxxxxx**********x**x*x*****z*****x**xxxxxxzxxxxxxxxxxxzx SECTION 3 -To be filled out by contractor "decontaminating tank": Tank Decontamination" Contractor: Address: (/- G3cYx 2G?6 Zip: Phone#: 2crr-S6�` 2noo Authorized representative of contractor certifies by signing below that the tank has been decontaminated in an approved manner as may be regulated by Department of Health Services. SIGNATURE AND TITLE xxxxxxxxxxxxxxxxxxxxzzxzzzxxxzxxzxxxxxxxz**x*x*z*x*x*****x*zzxx**x*xxx*xxxxxxxxzxxxxxxxxxzx SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, storage, or disposal facility accepting tank. Facility Name Address: Zip: Phone#: Date Tank Received: AUTHORIZED SIGNATURE AND TITLE xxxxzxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxzzxxxxxzxx*xx*******xxx*****x******x**xxzxxxxxxxxxxxzxxx E1! 23 049 11/88 MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. SAN JOAQUIN LOCAL HEALTH DISTRICT ATTN: UNDERGROUND TANK PROGRAM P. 0. BOX 2009 STOCKTON, CA 95202