Laserfiche WebLink
SAN JO • US N LO • <br />CAi., HF.Ar_TH DiSTR.2CT <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 <br />recycling facility. The holder of the Of with n <br />of the by disposal or <br />ensuringthat this form is com leted and returned.. umber noted below is resaonsible for <br />FACILITY NAME: fiJATrd i _ c Z/ <br />FACILITY ADDRESS: <br />TANK ID q39- 1710 <br />zzxzxxz*zxxzz**x**x*xx*zxx******xx**x*z* zz*xzz x x*xx *****X**zx <br />SFXTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: � A,, - � _..- <br />Address: <br />*xx*Xxx*z**xx*xz***zx**x <br />Zip: l �C3 / <br />Phone#: <br />Telephone; (,q6? j �!G ,; AGO o <br />*z**xzxz*xx**xx***x**xX*zz*zx*zxx*kxzxkX*Date <br />**zx*Tank <br />*Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": *zxz*zzx*kXxXz*xX**xkX*x**xx*x*xx* <br />Tank Decontamination" Contractor: <br />Address: <br />Zip: 4- C // <br />Authorized representative <br />hone 0: y _s-,2 a0 0 <br />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 />**k*k*k***xXxxk*Xxkkk*Xx*kXx*x**x*xx*kSIGNATURE <br />;tAND <br />**X*�kk*kk**kk*kkk***kXkk*k***k****k***k*kk <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 />Date Tank Received: <br />Exxzzxx*zzxxxxxxx******x*xk*x*zxAUTHORIZED <br />xzzxSIGNATURE <br />xxxxxxxxxxxxxxxxxxxxxxzxxxxxxxxxxxxxxx <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 />S'OCKTON, CA 95202 <br />