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SAN JOAQILJI N Loc-Ar• Y rF'z+.r.TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ******x**xxxx*x*x***x*xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx*x**********x****x****xxxxxxxxxxr <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 holder of the permit with nr noted below is responsible for <br /> ensuring that this form Is completed and returagd, <br /> FACILITY NAME: .5- v Al C C 4) <br /> FACILITY ADDRESS: J Y <br /> TANK ID 139- <br /> xxxxxxxxxxxxx x x xxxxxxxxxx,exxxxxxxxxxxzxxxzxxxxxzzzxxxzzxxzzxxxxxxxzxxzxxxxxxzxxxxxxxxxx <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 6--- <br /> Address: <br /> Address: '71 "J l (�, a� { r <br /> Zip: �- <br /> c. c_ ` Phone 1: <br /> r <br /> Telephone: Date Tank Removed: <br /> xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx*x*x***x**x******xx*********xxxxxxxxxxxxxx <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: q' riy I rO o ✓ii P... 4 c-j2- <br /> Address: Zi <br /> n ,k s C o ('A Phonel: �IS <br /> �`- Q1�i tl � C i O co4�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 /> SIGNATURE AND TITLE <br /> *xxxx**xxx**xxxxxxxxxxxxxxxxzxx*******xxxxxxzzxxxxxxzzzx***xx****z**xzxxx*xxx*xxxxxxxxxxxxx <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: �3u LA" h � Zip: 95�io 7 <br /> :Ic ,c `�' , � zip: <br /> L= eft ,�f c, c A D oc 5' 77/ i ms' <br /> Date Tank Received: <br /> AU'T'HORIZED SIGNATURE AND TITLE <br /> zxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxzxxxzxxzzxxzxxxx,exzxxzzxzxxxxzxzxxzxxxxxxxxx*xxxxxxx <br /> Ell 23 019 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AF71X PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />