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S J XJIN LOCPLTI HFKWI .� DISTRICT <br />UNDERGROUND TANK DISPOSITION TRACKING RDOORD <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 number noted below is responsible for <br />ensuring that this form is completed and returned._ <br />FACILITY NAME: <br />FACILITY ADDRESS: <br />TANK ID #39- 14P4 <br />**************** <br />SECTION - 2 - To <br />Tank Removal <br />Address: <br />5. <br />filled out by 'tank removal contractor: <br />tor: tom' ZE AS►On!S 1ft.l-tri INC, <br />ip. <br />Telephone: ( ) Date Tank Removed: <br />******************************************************************************************* <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: <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 4 - To b7fil3ed out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Name <br />Address: <br />c. <br />Date Tank Recei <br />AUTHORIZED SIGNATURE AND TITLE <br />Eli 23 049 12/88 <br />14AILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. O. BOX 2009 <br />STOCKTON, CA 95202 <br />Zip: <br />